










3* " 



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V 






;.- .^"\ 




T it b A T I S 



ON 



VENEREAL DISEASES 



BY 



A. VIDAL, (de Cassis,) 



SURGEON OF THE VENEREAL HOSPITAL OF PARIS *, AUTHOR OF A " TRAITE 



DE PATHOLOGIE EXTERNE ET DE MEDECINE OPERATOIRE, 
IN 5 VOLS., ETC., ETC. 



WITH COLOKED PLATES. 



TRANSLATED, WITH ANNOTATIONS, 



GEORGE C. BLACKMAN, M.D., 

FELLOW OF THE EOTAL MEDICAL AND CHIRURGICAL SOCIETY OP LONDON; FORMERLY ONE OF 
PHYSICIANS TO THE EASTERN AND NORTHERN DISPENSARIES, NEW YORK. 



SECOND EDITION. 



NEW YORK: 
SAMUEL S. & "WILLIAM WOOD, 



261 PEARL STREET. 
1855. 



> 






>* 



Entered, according to Act of Congress, in the year 1854, by 

SAMUEL S. & WILLIAM WOOD, 

In the Clerk's Office of the District Court for the Southern District of New York. 






STEEEOTTPEDBT PRINTED BT 

THOMAS B. SMITH, E. N. GROSSMAN, 

82 & 84 Beekman Street. 82 & 81 Beekman St 



PREFACE OF THE EDITOR. 

In preparing the Treatise on "Venereal Diseases of M. Vidal for the 
press, the American editor has aimed to furnish the reader not only with 
a faithful translation, but also with the views of some of the leading 
British and American practitioners. Messrs. Vidal and Ricord are both 
attached to the Hopital du Midi, the great venereal hospital of Paris, 
but in many respects the doctrines of our author are directly opposed to 
those of his distinguished rival. The annotations of the editor will be 
found to correspond, generally, with the views of the author, and he 
has been personally assured by many of the most prominent surgeons 
in Great Britain and this country of their cordial assent to the doctrines 
here inculcated. To Mr. Samuel A. -Lane, of the Lock Hospital, London, 
and to Mr. Langston Parker the distinguished syphilographer of Birming- 
ham, he would return his warmest acknowledgments, as well as to Dr. 
Byrne of the Westmoreland Lock Hospital, Dublin, and to Messrs.. 
Cusack, Porter, Adams, Egan, Fleming and Wilmot of that city, for their 
very polite attentions and for the communication of many valuable facts 
by which the object of his visit was greatly promoted. 

Although American syphilographers are few in number, yet we may with 
pride refer to the contributions of Dr. John Watson, of the New York 
Hospital, " On some of the Remote Effects of SypMlis" published in the 
first and fifth volumes of the New York Journal of Medicine and Collat- 
eral Sciences, and to the elaborate paper of Dr. H. D. Bulkley, " On Syph- 
ilis in Infants" in the ,JVew York Journal of Medicine and Surgery for 



iv EDITOR'S PREFACE. 

October, 1840. The value of these can be better appreciated in another 
part of this work. Through the politeness of Dr. Van Buren, the editor 
has recently had an opportunity of seeing (though too late to incorporate 
the details in his Notes) an instance of that exceedingly rare affection, 
tertiary syphilis in the infant. In this patient, there were nodes on the 
ulna and forehead, and enlargement of both testicles ! The article on Stric- 
tures of the Urethra, omitted in the Treatise of M. Vidal has been sup- 
plied by a somewhat free translation of that in the author's well-known 
work on External Pathology. For the remarks under the head of 
Urinary Infiltration, and Urinary Abscesses, the editor is alone responsible. 
In illustration of these subjects he has also added a few woodcuts, bor- 
rowed from various sources, and although some may consider these topics 
as foreign to a special Treatise on Venereal Diseases, he is disposed to 
believe that the junior practitioner will not regret the liberality of his 
publishers which has enabled him to make these additions. 

GEORGE C. BLACKMAN. 

New York, Jan. 1st, 1854. 



fta&U of CflttUitts 



PAGE 

Preface 1 

Introduction 13 

Synonyms 13 

Historical Sketch 14 

Syphilitic Yirus 19 

Observation 26 

Experiment 32 

Inoculation. , 33 

Inoculation of Animals 36 

Syphilization 40 

Transmissibility of Secondary Accidents 49 



PART I. 

PEIMITIYE VENEREAL *DISEASES 67 

CHAPTER I. 

Blennorrhagia 68 

, CHAPTER II. 

Blennorrhagia in the Male *72 

Section I. — Blennorrhagia of the Urethra *72 

Consequences of Blennorrhagia 88 

Blennorrhoea 88 

Uretrorrhagia 119 

Urethral Pains. . . .«. 122 

Perverted Sensations in the Urethra — Absence of Sensations 124 

Blennorrhagic Orchitis 126 

Blennorrhagic Prostatitis 139 

Blennorrhagic Cystitis . . . ' 146 

Blennorrhagic Nephritis 149 

Blennorrhagic Ophthalmia 153 

Blennorrhagic Arthritis 158 

Section II. — Blennorrhagia Balano-preputial 163 



V! TABLE OF CONTENTS. 

CHAPTER III. 

PAGE 

Blennorrhagia in the Female 172 



CHAPTER IV. 

Blennorrhagia in both Sexes 188 

Anal Blennorrhagia 189 

Buccal Blennorrhagia 190 



CHAPTER V. 

Chancre 190 

Diseases which may be regarded as accidents of Chancre, Phimosis, and Para- 
phimosis 227 

Phimosis 227 

Paraphimosis 229 



CHAPTER VI. 
Bubo 234 

CHAPTER VII. 
Vegetations 255 

CHAPTER VIII. 
Mucous Tubercles S>> ' 



PART II. 

CONSECUTIVE VENEREAL DISEASE (VEROLE). 

CHAPTER I. 

General Remarks 277 

Section I. — Symptoms 277 

Section II. — Period and Order of Appearance > 278 

Primary Accidents 281 

Secondary Accidents 281 

Tertiary Accidents 281 

Section III. — Exciting Causes 283 

Section IV. — Syphilitic Fever 285 

Section V.— Blood of Syphilitic Patients 286 



TABLE OF CONTESTS. yii 

PAGE 

Section VI. — Can a person have syphilis more than once ? 290 

Section VII. —Therapeutics 292 

I. Mercury 293 

External employment 293 

Internal use of Mercury 300 

Mercurial Compounds 301 

II. Other Mercurial Preparations 305 

III. Accidents produced by Mercury 305 

Salivation and Stomatitis , 305 

Cholic and Diarrhoea, Mercurial Tremors 315 

TV. Iodine 316 

V. Iodide of Potassium.; , 317 

Accidents attributed to Iodide of Potassium 322 

VI. Iodide of Iron 324 

VII. Gold, Silver, Platina 325 

VIII. Double Salts * , 328 

IX. Sudorific Woods 329 

X. Compounds, partly mineral, partly vegetable 330 

CHAPTER II. 

On Special Consecutive Venereal Affections 331 

Section I. — Syphilitic Eruptions — Syphilides 331 

I. General Characters 332 

II. Varieties 336 

Exanthematous Syphilitic Eruptions 337 

Syphilitic Papular Eruption 338 

Syphilitic Squamous Eruption 340 

Syphilitic Vesicular Eruption 341 

Syphilitic Bullae 344 

Syphilitic Pustular Eruption 34*7 

Syphilitic Tubercular eruption 365 

III. Causes 370 

IV. Diagnosis 372 

V. Prognosis 374 

VI. Treatment 375 

Internal Treatment 375 

External Treatment 376 

Section II. — Diseases of the Appendages of the Skin 378 

I. Loss of the Epidermis 378 

II. Alopecia. „ 378 

III. Onyxis 380 

Section III. — Affections of the Mucous Membranes 383 

I. Mucous Membrane of the Mouth 384 

II. Mucous Membrane of the Nose 392 

III. Mucous Membrane of the Genital Organs 394 

IV. Mucous Membrane of the Epiglottis and Larynx 396 

V. Mucous Membrane of the Ear 397 

VI. Mucous Membrane of the Anus and Rectum 397 

Section IV. — Affections of the Eyes 399 

Syphilitic Iritis 899 



viii TABLE OF CONTENTS. 

PAQB 

Section V. — Diseases of the Testicles 407 

Syphilitic Sarcocele 407 

Section VI — Diseases of the Cellular Tissue 418 

Section VII. — Affections of the Muscles, Tendons, and Aponeuroses 420 

Section VIII. — Affections of the Bones and Periosteum 427 

I. Osteocopes 428 

II. Periostitis and Ostitis 431 

Periostitis 431 

Ostitis 433 

III. Exostosis 435 

IV. Caries and Necrosis 443 

Section IX. — Affections of the Viscera 447 

I. Cerebral Affections 448 

IL Hepatic Affections. . , 450 

III. Cardiac Affections 451 

IV. Pulmonary Affections 452 



PART III. 

INFANTILE SYPHILIS 458 



PART IV. 

PROPHYLAXIS OF VENEREAL DISEASES. 

CHAPTER I. 
Private Prophylaxis 488 

CHAPTER II. 
General Prophylaxis — Medical Police 493 



PREFACE. 



Innumerable are the works on venereal diseases, but the majority have 
been written for the purpose, more or less candidly admitted, of establish- 
ing or overthrowing some particular doctrine. Many volumes have been 
devoted to the vindication or subversion of the dogmas that emanated from 
idealism, and the school of Galen, as well as from his successors, the chem- 
ists and the vitalists. The same is true of the school of Broussais, which 
so recently denied the existence of a venereal virus, and of those who be- 
lieved, on the other hand, in the entity of this virus. These productions 
have sometimes exhibited marks of genius, and have been distinguished by 
their elevated and splendid diction, but they were designed only for those 
acquainted with the subject. I write for a different class, and for those 
who have but little time to devote to the study of these affections. I pro- 
pose to collect such facts and opinions as are of practical application, and 
which have survived the wreck of systems, the founders of some of which 
showed themselves profound observers. With this view, I have selected a 
plan sufficiently extensive to embrace the most important practical details, 
and yet which, without having too wide a scope, will, I trust, enable all to 
comprehend the substance of our knowledge on the speciality now termed 
syphilography. 

From the time that venereal diseases were first somewhat carefully 
studied, it has been admitted, that, shortly after the application of the 
virus, certain lesions are generally produced on the parts contaminated ; 
these are the primitive venereal accidents. Again, there are certain other 
morbid conditions, which are ordinarily observed subsequently to the 
above ; these are the consecutive venereal accidents. Under this by no 
means modern division, these affections may be advantageously studied. 
I have adopted it, believing it to be the most rational and best adapted to 
the purposes of instruction, and not as serving as the basis of any particu- 
lar system. 

Hunter recognized two varieties of the consecutive or constitutional dis- 
ease, and M. Ricord having availed himself of this subdivision, includes 
all the accidents under the heads of primary, secondary, and tertiary vene- 



x PREFACE. 

real disease. In this species of triad, of ancient date,* this writer fancied 
that he had discovered the basis of a true classification, on which he has 
engrafted not only a system, but a system the exact symmetry of which 
was well calculated to captivate an age inclined to absolute certainty, 
whilst its apparent simplicity has been greatly admired by certain minds, 
which it is unnecessary here to characterize. A distinguished writer has 
remarked, that system and hypothesis are synonymous terms-; now we 
know the result of subjecting the latter to a somewhat rigid criticism. 
Still this system seemed to withstand not only the force of reason, but of 
arguments based on clinical observation. It rested its claims upon exper- 
iment, the influence of which may be imagined during the period to which 
we have alluded. Its opponents were therefore compelled to descend to 
the same ground, and it was attacked with the same instrument, as it were, 
that had been employed in its establishment. Various were the experi- 
ments performed, and the proceedings adopted. Some of these proved, 
that chancre was not the only accident that admitted of inoculation, but 
that those termed consecutive might also be thus transmitted. Now as 
the system was based essentially upon the exclusive inoculability of chan- 
cre, these results struck at its very foundations. They likewise seriously 
compromised the classification dependent on it, as the only admitted dis- 
tinction between chancre and the other accidents was thus destroyed. 
Other experiments showed that chancre itself, or the most virulent syphi- 
litic poison, from some natural or accidental cause, was perfectly harmless 
when applied to certain individuals ; therefore, as the system boasted as 
its test for syphilis, the infallibility of chancrous inoculation, it found 
itself wanting in view of its practical application. 

Thus, the immutable laws, of experiment, proclaimed by M. Ricord, were 
annulled by experiment itself, and the promised certainty resulted in un- 
certainty.! It required but a slight knowledge of medical philosophy, and 
a little reflection upon the results of experiments, according as they are 
performed in the exclusively physical, or in the exclusively pathological 
order, to have anticipated what here occurred. Then came the cases prov- 
ing that the secondary might appear after the tertiary accidents, and vice 
versa. The order of the system being thus compromised, what remained ? 
In the body of this work may be found the proofs of what has been here 
asserted. However, I shall be brief upon these points, for the main ob- 
ject of this work is to collect the practical truths which are the results of 
observation, and those which have survived the downfall of systems. Still 

* Vid. "La methods curatoire de la maladie venerienne" of Thiery de Herry, and p. 
259 of this "work, where I have exposed this triad in its author's ovn words. 

f In the Introduction, under the heads of Inoculation and Syphilization, behold the 
glimmer thrown by the eloquence of M. Malgaigne, over the enormous breaches in 
the system of which this Professor was at one time a defender, and which had foi 
its leader a friend of twenty years' standing! 



PREFACE. xi 

I have thought it my duty to warn the young practitioner against disap- 
pointments and regrets, there being nothing, in my opinion, more danger- 
ous, either in study or in practice, than to invest mere forms with cer- 
tainty, and to pronounce that to be infallible which can be but probability 
or uncertainty. After the two principal divisions, — primitive and con- 
secutive venereal diseases, — will follow the section on infantile syphilis. 
In this, we shall discuss the questions of the hereditary descent of the dis- 
ease ; its transmissibility from the child to the nurse, and from the nurse 
to the child. The importance of this chapter is evident, for, in the opin- 
ions there examined, the interests of the family, of justice, and of society 
in general, are involved, and yet the majority of French works on these 
topics are very incomplete ? In the fourth part, we shall consider the 
prophylaxis of venereal diseases, including general and private prophy- 
laxis, and regulations of medical police. 

In the Introduction, after a few observations upon the synonyms, may 
be found an historical sketch of the venereal disease. I shall express an 
opinion on the nature of the syphilitic virus, and its principal effects. The 
causes of error in observation will be shown; experiment justly appre- 
ciated ; the process of inoculation explained, whilst syphilization will be 
judged. This introductory chapter will conclude with some general ob- 
servations on the transmissibility of secondary accidents. 

Since I have stated, in the commencement, that I propose to make a 
resume of the facts, opinions, and therapeutics, constituting syphilography, 
my great indebtedness to my predecessors will be obvious. All shall be 
quoted with acknowledgment. I will submit to the reader what expe- 
rience has taught me at the Zmircine, in the female wards; and what I 
have learned at the Hopital du Midi, during a service of more than ten 
years, since I became the successor of Cullerier, — -the honest man, the sage 
practitioner. 

Placed in a theatre so vast, I could not remain indifferent to questions 
by which science was agitated. I have ventured to discuss one of the 
most important, the transmissibility of the secondary disease. I think 
that, by experiment, I have decided it in favor of the contagionists. My 
experiments have been repeated in France and in Germany; all have pro- 
duced a brilliant discussion in the Academy of Medicine. MM. Vel- 
peau, Lagneau, Gribert, Grerdy, and Roux,* maintained, with their well- 
known abilities, the transmissibility of the secondary accidents, and what 
is without a parallel in the annals of the Academy, the opposite side of 
the question had but one defender ! If from France we pass to foreign 
lands, we shall find that the opinions of learned academicians are generally 

* It will be observed that among these orators are two distinguished syphilogra- 
phers, and three professors of the Faculty of Paris. Read their discourses in the 
Bulletin de VAcademie de Medecine, where they are correctly reported. (Nos. for 
Oct. et suiv. 1852. 



xii PREFACE. 

divided. We may see, particularly in the German press, how ably this 
doctrine has been sustained by Waller, Simon, and Droste. 

To facilitate the study of the venereal accidents, the most important to 
be known, I have illustrated them by colored engravingSj from designs 
which it is unnecessary for me to praise since they were executed by M. 
Bion. The necessity of these will be admitted when we come to the chap- 
ter on the cutaneous affections, for we know the importance of the syphi- 
litic tint in forming our diagnosis, and the difficulties which the student 
encounters who wishes a tableau of the principal varieties. He will find 
it here, true to nature. 

Lately, some syphilographers whose tenets have been shaken, have 
allowed themselves to descant bitterly, or in a jesting tone. They have 
even written in the same style. Having no motive for sharing in the sen- 
timents which have inspired a literature of this kind, having, besides, re- 
marked that it has neither thrown light upon, nor advanced the questions 
in dispute, I have abstained from it, and have endeavored to speak as 
clearly as possible, the language of science, since it is the latter only which 
I have in view, and the interests of those who would become her earnest 
votaries. 



INTRODUCTION. 



The object of this is to assist trie comprehension of matters 
which constitute the body of the work ; it contains also a critical 
exposition of the method of investigation, and generalities on the 
great questions of syphilography. Thus, after a few remarks upon 
the synonyms, and a brief history of the venereal disease, I will 
describe the method, observation, and experiment applicable to 
this specialty. I will speak of syphilization, and conclude with an 
article on the transmissibility of secondary accidents. 



SYNONYMS. 

The diseases which I am about to investigate have received an 
infinity of names, sometimes originating from their mode of propa- 
gation, sometimes from a prominent symptom, sometimes from 
the country accused of giving birth to the malady, or from the peo- 
ple who communicated it to strangers ; sometimes, indeed, from 
fable. Thus they were called venereal, from the fact that they were 
generally contracted during the venereal act ; verole signifies pus- 
tules on the skin, which are observed in certain stages of the 
disease, and which have been considered analogous to those of 
variola ; and they were called Mai francaise, Mai napoliiain, be- 
cause the French and the Neapolitans were supposed to have com* 
municated them to other nations. Other people, too, have, in 
their turn, been accused, and have contributed in giving a name 
to these diseases ; the Turks as well as the Germans, the Poles as 
well as the Moscovites, &c, &c. But it must be admitted that 
the French, in this respect, have gained the greatest notoriety. 
Syphilis is the creation of Fracastor ; in his poem he imagines that 
the shepherd Syphilus, was the first who was smitten with the 
disease, which the gods, in their wrath, invented. I will not 
exhaust this subject, which might be made to fill many pages ; with- 
out interest, however, either in a scientific or practical point of 
view. The names still employed are these: Venereal Disease, 
Syphilis, Verole. Some physicians use them indifferently. Never- 
theless, the first is generally adopted, as it indicates the most 
common source of the disease, viz., coitus, or other libidinous 
connections. Syphilis denotes that a virus, a morbid poison, has 
intervened, and that it plays a principal part, whilst verole or con- 
stitutional syphilis signifies that this virus has produced a profound 



14 INTRODUCTION. 

change in the organism, constituting, indeed, a diathesis, a disposi- 
tion, a temperament. This virus is sometimes inoculated by acci- 
dent, by a wound, and the affections to which it gives rise may be 
entirely independent of any libidinous act. At present, there is 
a patient under my care, at the venereal hospital, who, in a strife, 
was bitten on the thumb by his comrade, and who was thus, at the 
same time, inoculated with a chancre. 



HISTORY. 

I shall be brief in my sketch of the history of syphilis, shrouded 
as it is in darkness, and from no point shedding light upon doctrine 
or practice. The point most obscure in its history is that of its 
origin. Is it as old as humanity ? Is it modern, and did it origin- 
ate towards the end of the fifteenth century ? The vast learning 
of Astruc, the dates by him collected, and the commentaries which 
he has written in his efforts to solve these questions, have not in 
the least advanced our progress. We know, it is true, that Astruc 
is a believer in the modern origin of the disease, but we do not 
become acquainted with this fact until we have carefully perused 
his work unto the end. The majority of writers are opposed to 
Astruc, and maintain the doctrine of its ancient origin. To sim- 
plify the question, I should, in the first place, remark, that there are 
venereal affections which are not virulent or specific, as well as 
those that are. Now, no one can deny that the first have always 
existed; for in every age, inflammations, discharges, and ulcera- 
tions of the genital organs have been observed, caused by the too 
frequent indulgence in the venereal act, or by its performance 
during the menstrual period, or pregnancy, &c., &c. Thus, certain 
venereal affections had their origin in the earliest antiquity. The 
question remains to be settled, whether the specific disease, syphilis, 
in fine, is equally old, or whether it originated towards the end of 
the fifteenth century. In passing over the three principal phases 
in the history of these diseases, I shall endeavor to throw some 
light upon both of these questions. 

Antiquity. — It is true that in antiquity the venereal disease had 
neither name, therapeutics, nor a special treatise. But Moses pre- 
scribed the observance of certain precautions to prevent the con- 
tagion of gonorrhoea (profluvium seminis,) the blennorrhagia of 
modern times. Hippocrates alludes not only to ulcers on the 
penis, but to pustules and the loss of the hair. Celsus is more 
remarkable still, for if rightly interpreted, we find that he was 
acquainted with almost every kind of ulceration on the penis, and 
with our present notions, it is possible to recognize in his descrip- 
tions, not only chancre but several of its varieties ; as the common, 
and even the indurated chancre. Still further, Celsus points out 
the complication of phimosis, and of paraphimosis. But scientific 
distinctions could not have been established by Celsus, and it would 
be unjust to exact from him a diagnosis, to which many physicians, 
even in our own day, are incompetent. 






INTRODUCTION. 15 

In ancient times, everything was regarded as a result, and 
variety, of inflammation ; a specific cause was unknown, and the 
connection of the different symptoms was not recognized. How- 
ever, one fact, that of contagion, known to the most eminent, 
should have aroused the attention of the ancients; thus, Galen, 
with his genius, traced blennorrhagia to contagion, and his fol- 
lowers, in this as in other matters, adopted the opinions of their 
leader. As we depart from antiquity the elements of the disease 
become more distinct, and so connected as to constitute the vene- 
real disease with its special forms. Thus the Arabs and the 
Arabists are very instructive in a historical point of view ; Avicenna 
and Areteus describe a peculiar disease of the throat, which the 
latter calls the Egyptian disease, and supposed it to be confined to 
young people. The fact of its being contagious is distinctly 
noticed, and William of Salicet, Lanfranc, and B. Gordon had some 
idea of a specific cause : they note the deplorable consequences of 
carnal connection with unclean females, affected with discharges 
which even then they designated as virulent, (virulentes;) they 
refer to inguinal abscesses, genuine buboes having their starting 
point, the penis, and marked the cutaneous eruptions as constitu- 
tional affections, classing them with lepra. These abscesses were 
noticed not only as cold or hot, and distinct from their cause, but 
as having their starting point on the penis. Thus, we find this 
remarkable passage in William of Salicet; "And the bubo occurs 
when a man has a disease of the penis from connection with an 
unclean woman, or from every other cause, which gives rise to an 
accumulation of corruption in this organ, which corruption being 
unable to find an exit, returns to the groins, according to that law 
of affinity which these parts have with the infected organ." Lan- 
franc, who was a pupil of William, speaks of abscesses in the 
groin that follow ulcers on the penis : Scepe provenit aposihema in 
inguine propter ulcera virgce, proptera quod est decensus humorum ad 
ilia loca* Further, Lanfranc advises a method of prevention, 
which I will mention when I discuss the subject of prophylaxis. 
I will add, that even before the fifteenth century there existed, as 
for example in London, regulations of medical police for certain 
houses of prostitution. 

There can then be no doubt of the existence, in antiquity, of 
local non- virulent venereal diseases, and there is strong presump- 
tive evidence also, that there were those of a specific nature, which 
produced both local and constitutional symptoms. Thus, it is 
very probable, that more than one syphiloid affection might have 
been found in that confused mass of cutaneous diseases, and among 
those lepers so often noticed among the ancients, and which have 
not yet disappeared, as is maintained by the hygienists. What led 
to the use of mercury after the epidemic of the fifteenth century ? 
It was the success obtained in the earlier ages, when it was em- 
ployed for the cure of those diseases which were confounded with 
lepra, and among which were the syphilides. Is this not another 

* Pract. III., doctr. II., cap. IL 



IQ INTRODUCTION. 

proof showing the connection existing between the affections 
observed before the fifteenth century and those which occurred 
subsequently to this period? Further, as I have already stated, 
the diseases called leprous, have not yet disappeared ; but, having 
been more carefully studied, and better specialized, the part that 
lepra plays in the production of these affections, has been reduced 
to so narrow a compass that it would seem no longer to exist. 
That belonging to syphilis could not be shown without under- 
standing the dependence existing between the primitive and the 
consecutive accidents, the cutaneous eruptions ; now this depend- 
ence was unknown to the ancients; ignorant of the interval 
between the phenomenon of inoculation (primitive accident), and 
that of infection (consecutive accident), these two elements of the 
same malady have passed for two distinct diseases, proceeding 
from a different cause. Perhaps this kind of incubation of the 
consecutive affection, was in ancient times of longer duration, from 
circumstances which we cannot appreciate, and thus a new obstacle 
has been added to our progress. 

Fifteenth Century. — During this epoch many persons were smit- 
ten with a scourge which has been represented as cruel and dis- 
gusting. The skin of the afflicted was covered with numerous 
pustules, agonizing pains racked their limbs and head, resembling 
those sow called osteocopes rhumatoides ; these were accompanied 
with sleeplessness, scalding of the urine, and fever. It was partic- 
ularly during the latter part of this century (1495), and at Naples, 
whilst it was occupied by the French army commanded by Charles 
YIIL, that this scourge was most violent, and counted its greatest 
numbers of victims. The rapidity with which the disease spread, 
the extent of country over which it travelled, gave to it the char- 
acter of an epidemic ; on which account, this period in the history 
of syphilis has always been known under the name of the epidemic 
of the fifteenth century. 

But if, as was thought by some authors, this was a new malady, 
others again regarded it as a degeneration or aggravation of an- 
other disease. It was a kind of maranique pest, or indeed, an 
affection analagous to the epidemic lichen of Hippocrates, or a 
mentagra, having also an epidemic character. It is not surprising 
that, at this epoch, a certain conjunction of the stars should have 
been regarded as its cause ; and still less that the atmosphere, the 
breath of speech, should have been considered the vehicle of the 
morbific principle. What first struck the observer, was the state 
of the skin covered with pustules, and the pains in the limbs with 
which the patient was tormented. The lesions of the genital or- 
gans were unknown, or appeared of but little consequence, com- 
pared with those which shortly followed. It is even probable 
that these lesions, which at this day are called primitive accidents, 
were sometimes completely absent. For my own part, I am in- 
clined to think that such was the case, especially since I have 
proved in so positive a manner, the transmissibility of the pus- 
tular form of the syphilitic eruptions ; indeed, at a certain pe- 



INTRODUCTION. 17 

riod, the pustules on the skin may be transmitted from a diseased 
to a sound person. 

"Whatever may be the explanation, the disease was considered 
not only as epidemic, but contagious, and different nations ac- 
cused each other of having spread the plague. When the 
American origin of the disease was invented, these mutual accu- 
sations of European nations were somewhat checked. It was 
supposed that the Spaniards, on their return from the conquest 
of the new world, had brought with them a new malady, which 
they scattered in Italy, where, at that time, was stationed a French 
army. This opinion of the American importation, has, found and 
still counts, many advocates. Numerous serious objections have 
been urged against it. M. Eicord, for example, who believes in 
the exclusive inoculability of the primitive affection, thinks it very 
astonishing that this should have retained its virulence during the 
long voyage of the Spanish sailors, and the long time which must 
have passed before their arrival in Italy. To this we may reply, 
that the consecutive affections may also be inoculated, and that the 
disease of the army in Italy having been specially characterized 
by the existence of pustules, these might have occurred among 
the Spaniards during the voyage. But there is a still more em- 
barrassing objection against the doctrine of importation, based 
upon the immunity of the Spanish ports, when these voyagers 
first landed, and where they resided, and this too, after the long 
continence which had been forced upon them. Thus, it is well 
known that the greater part of the crews of Columbus remained 
at Seville, and yet this city did not suffer from the disease sup- 
posed to have been imported by these navigators. They could, 
therefore, have been dangerous only to the Neapolitans, and this 
too after having failed to contaminate the Spaniards ! Besides, 
when the Spaniards arrived in Italy, this, like other European 
countries, was already infected. Swediaur goes so far, indeed, as 
to assert, that Europeans, the Spaniards — carried the disease to the 
new world. But I know not why the believers in the American im- 
portation of syphilis, would find no trace of it in antiquity ; for, ad- 
mitting their opinions to be true, we are compelled to ask, how did 
it originate in the new world. The question then of the first origin 
of syphilis, according to this view of it, is only shifted, not solved. 

However this epidemic of the fifteenth century may have orig- 
inated, to us it appears to have been accompanied with symptoms, 
in many respects different from those of the syphilis of antiquity, 
or of our own day. The illustrations given by those who ob- 
served the epidemic under consideration, show us, indeed, many 
traits in common with the modern disease, but certain tints and 
colors prove that the lesions really belonging to syphilis, were 
blended with certain other lesions and general symptoms, which 
render probable the existence of serious complications, arising 
from unfortunate hygienic conditions, or from very corrupt man- 
ners. Finally, it is quite probable that other diseases of a serious 
character prevailed at the same time with syphilis, and that they 
were mutually complicated with each other ; thus lepra, typhus, 



18 INTRODUCTION". 

farcy, blended with syphilis, have been supposed to have given 
to the scourge of the fifteenth century the fearful character which 
it assumed. A strong argument in favor of this hypothesis, is, 
that the worst cases of syphilis observed at the present day, are 
found among the unfortunate beings who are compelled to suffer 
great privations, or who are laboring under a strumous or scorbu= 
tic diathesis. Under these circumstances, we sometimes find re- 
produced more than one feature in the horrible picture furnished 
by the fifteenth century : for example, I have at present under 
my care an excessively feeble young man, of a scrofulous habit, 
whose body is covered with pustules, whilst his lower extremities 
are affected with rupia, deeply excavated ecthyma, with cracked 
black crusts. Under these scabs, ulcerations have burrowed, some 
of which have taken the serpiginous form, and are the seat of 
atrocious pains. Has this case not more than one feature in com- 
mon with the scourge of the fifteenth century, which has been de- 
nominated morbus pustularum f The pathognomonic signs of sy- 
philis become more distinct and easy of recognition, in proportion 
as we isolate them from the diseases with which they were com- 
plicated, and from the epidemic influences by which they were 
modified. Then indeed, we may collect the elements of syphilis, 
and establish a form of disease entitled to a scientific nomencla- 
ture. In alluding to the earliest period in the history of the vene- 
real disease, I have stated, that it could then boast neither of 
name, therapeutics, nor of books ; but from the commencement 
of the sixteenth century, it has received many names, has had a 
special therapeutics, and has given rise to innumerable volumes. 

Sixteenth Century. — A great genius now appears ; his name forms 
an epoch ; it is Fernel. Now a specific cause is discovered, the 
local and general symptoms are recognized. True, in 1552 James 
Bethemont had furnished Fernel with a hint of the fact ; and Para- 
celsus, during the prevalence of the epidemic had seized upon the 
symptoms peculiar to syphilis, with the design of forming a new 
species in pathology. But Fernel will always maintain his place 
at the head of the truly scientific epoch of syphilis, and this too, 
with the greater justice as subsequent ages have made but few 
additions to his teachings. Not only did Fernel scientifically es- 
tablish the necessity, and the existence of a specific cause, but he 
traced it from a diseased to a sound person ; he demonstrated its 
transmissibility by different modes of contact, especially by the 
venereal act, whence the name of Lues Veneris. The disease 
had its name, and its cause ; symptoms were recognized and de- 
scribed ; they were the primitive, and the consecutive or constitu- 
tional symptoms ; in fine, the application of the poison, its local 
effects and general results, were traced with a masterly hand by 
Fernel. But, when he attempted to classify the effects of the virus 
according to the depth which it had invaded, when he had the 
presumption to establish four varieties of the malady, according as 
it progressively attacked the four layers of tissue between the skin 
and the bone ; then, and then only, was he misled, as are all those 
who would imitate him, and number the varieties of the disease. 



INTRODUCTION. 19 

The fundamental part of his doctrine, however, still reigns in the 
schools to which it has descended, especially through the labors of 
Astruc. 

SYPHILITIC VIRUS. 

This, according to Hunter, is a morbid poison, resulting from 
disease, which poison, unlike other toxic agents, may reproduce a 
similar disease. 

The syphihtic virus, in substance, cannot be detected; in its 
simple unmixed state, it eludes all our efforts at observation ; here, 
micrography and chemistry have shown their impotence. This 
poison is manifested only by its effects, of which the most remark- 
able is its great facility of reproduction. Brought into certain re- 
lations with the living tissues, and in certain conditions, the virus 
develops a morbid action, the result of which is its reproduction, 
its multiplication. It is there a kind of germination, for the cause 
produces an effect which becomes of itself again the cause. Obser- 
vation has demonstrated the existence of a syphilitic virus, for the 
number is infinite who have contracted chancres by connection 
with those affected with chancres. But to remove the doubts of 
certain minds, a resort must be made to experiment. In fact, pus 
from a chancre, inserted on the point of a lancet beneath the epi- 
dermis, has given rise to the same form of ulceration, possessing 
the same property of reproduction. 

The syphilitic virus has ordinarily for its vehicle a thin, sero- 
sanious, mal-assimilated pus, in which organic detritus is more or 
less apparent. But pus the most laudable, muco-pus, may also be 
the means of conveying the virus, and it would seem to possess no 
influence in modifying its nature. The virus may exist not only 
in the morbid secretions, but it has not been proved that it may 
not change the normal secretions. It unites with the blood, and 
there undergoes certain modifications by which it becomes inti- 
mately blended with it. A particular kind of pus, that produced 
by gangrene, seems to neutralize the virus. 

Virulent pus may, like vaccine matter, for a long time be pre- 
served in tubes, or between two glass plates, without losing its 
properties ; of this Percy has furnished the proof. But to develop 
these properties of pus, it must be applied in a liquid state, or be 
so placed that it will be rendered such by the moisture of the part 
in which it is inserted. Even when greatly diluted, a solution of 
this pas may be inoculated, and M. Puche has shown that one 
drop in a glass of water suffices to render this liquid virulent. 
This is worthy of note, as it sanctions what I denominate physio- 
logical absorption of the virus, and will place us on our guard 
against the use of water which has been used for bathing or for 
washing by those affected with the venereal disease. 

The gastric juice, or a solution of the sulphate of iron, does not 
change the properties of the virus (Hernandez). Certain acids 
destroy it. This however will be more fully noticed when we 
come to the subject of prophylaxis. 



20 INTRODUCTION. 

Is there more than one virus ? The existence of a virus is no 
longer doubted, but the question constantly arises, Is there more 
than one virus possessing different strength and different qualities ? 
This question has been proposed by every syphilographer who has 
sometimes met with such different effects from the virulent matter. 
Thus, they have asked, Is there not one virus which inflames, and 
another which gives rise to ulceration ? Or, to speak more cor- 
rectly, Is not Menorrhagia produced by one kind of virus, and 
chancre by another ? To these, Hunter replied in the negative, 
and explained the different effects by the difference in the surfaces 
to which it is applied. If specific pus is brought into contact with 
secreting surfaces, Menorrhagia is the result (these surfaces are the 
lining membranes of the vagina and urethra) ; if the same pus is 
applied to the skin and the mucous membranes bordering upon it 
(as, for example, those of the glans, the prepuce, the vulva, and the 
lips), a chancre will follow. But as chancres have been observed 
in all the mucous membranes to which it has been applied, the 
theory of Hunter was necessarily abandoned. A double virus 
was then adopted as a substitute, and this doctrine was defended 
by Benjamin Bell and Hernandez. I shall notice this theory when 
I treat of blennorrhagia, but I feel bound here to show how it has 
been defended by Hernandez, in the face of arguments deemed most 
weighty, since they were derived from the results of experiments. 

An experimenter by the name of Andre inoculated himself with 
gonorrheal matter, which produced a chancre. To this fact Hernan- 
dez replies that it is of but little importance as it is an isolated one, 
and because it has been reported by an unknown surgeon. But 
Hunter likewise produced chancres in the same manner. The ob- 
jection now raised by Hernandez, is, that these ulcers healed 
spontaneously, and consequently they could not have been chancres ! 
But he had a bubo which was followed by consecutive symptoms. 
The bubo, replies Hernandez, might have arisen "from the irri- 
tation of the ulcer of the glans." The consecutive accidents, such 
as ulcers in the throat and pustules, might have proceeded from 
other causes. We have just seen, that Hernandez would not be- 
lieve Andre, because he was unknown ; should we not suppose 
that the name of Hunter, so widely known, would therefore in- 
spire him with the greatest confidence? Far from it, however, 
and he concludes by saying ; " can we moreover place much de- 
pendence on the syphilitic nature of all the affections pronounced 
venereal by distinguished physicians?" 

Still farther, Hernandez believes not even his own experiments. 
Thus, he inoculated convicts who preferred the operation to the 
labor of the arsenal. In seventeen, ulcers occurred which had no 
appearance of syphilis, and which were promptly cured without 
internal treatment. "In the others," says Hernandez, "it pro- 
duced obstinate ulcers, some of which had every appearance of 
syphilis, with the general symptoms which would seem to establish 
it. Two were cured only after using mercury. Should we not 
suppose that our experimenter having inoculated twelve out of 
seventeen of these convicts with chancre, and that too with the 



INTRODUCTION. 21 

mucopurulent discharge of gonorrhea, would have believed in the 
possibility of producing chancres with this same pus? But no, 
these ulcers could not have been venereal, as they occurred in 
scorbutic and scrofulous subjects ! Now Hernandez himself se- 
lected his own subjects for these experiments. Of course, he must 
have known previously that they were the victims of scurvy and 
the king's-evil ! I have quoted the above remarkable passage from 
Hernandez to prove not only the identity of the pus of blennor- 
rhagia and chancre, but also to show for once that experiments, no 
more than observation, can destroy systematic prejudices, or guard 
against subtilities, since we ' here see Hernandez, possessed with 
this idea of a double virus, resisting the most substantial proof 
drawn not from the experiments of two physicians only, but even 
from his own. For him, theory was stronger than proof* It 
is generally supposed that it is peculiarly in our own day that 
imagination plays so active a part in positivity (posilivisme), but 
this is a great mistake. 

Hernandez having besides at his disposal the chancre larve — since 
he invented the term — availed himself of it, but without abusing 
it. M. Kicord has again brought this forward, but he has abused 
it. According to his views, there is but one virus, that of chancre. 
Blennorrhagia is but a catarrhal inflammation, like any other 
arising from a simply irritating cause, but it has no connection 
with syphilis. When by accident, we succeed in inoculating a 
chancre from the urethral discharge, and when this discharge has 
been followed by constitutional symptoms, then the patient could 
not have had blennorrhagia proper ; the discharge comes from a 
chancre hidden from our observation, deep in the urethra — a 
chancre larve — since we must call it by its name.* Now, although 
some of these hidden chancres may be discovered, others cannot be 
found. I have stated that Hernandez invoked their aid, and we 
know that before Hernandez and M. Eicord, when evidence was to 
be destroyed, in the absence of other arguments recourse was had 
to occult causes. The human mind has never been more fertile 
than in this respect ; generally it retards, when it would advance 
our progress. Thus we cannot be accused of sustaining our views 
by superannuated Theses. 

Let us see, moreover, if the admission of a single primary ac- 
cident, that of chancre, removes the difficulty. Granted, for the 
sake of argument, that the specific virus, which gives rise to con- 
secutive symptoms — to syphilis — is secreted by chancre alone. But 
there will always remain a disease of the mucous membranes, with- 
out ulceration, occurring under the same circumstances as chancre, 

* Under the head of Blennorrhagia, we shall attempt to show that our author's 
observation applies with equal force to M. Rieord, and we think that we shall be 
able to prove, even by the experiments of this distinguished surgeon, that blennor- 
rhagia is occasionally inoculable, and that too, under circumstances in which he 
does not intimate his suspicion of the existence of a concealed chancre. — Gr. 0. B, 

f I am satisfied, as must be those who have carefully examined the two patho- 
logical specimens on which M. Rieord ■ relies to establish his theory, that they 
were tubercular ulcerations * f the urethra, similar to those observed in the prostate 
glands of the same patient. 



22 INTRODUCTION. 

and which in the same individual produces metastatic affections, 
such as opthalmic and arthritic inflammations ; there will always re- 
main a disease, caused by contagion, which is not a simple phleg- 
masia, and which gives rise to primitive effects, such as I shall in 
another place describe. If in this we do not see a specific disease, 
if we refuse to admit that the two lesions are produced by the 
same virus, we must find some other cause, some other virus, and 
with Benjamin Bell, we must adopt the doctrine of a double virus, 
one for gonorrhea, one for chancre. Still, even here, we originate 
nothing, we only revive the doctrine. 

To explain the difference between blennorrhagia and chancre — 
their primitive and consecutive accidents — a virus of different 
strength has been admitted, a whole virus, and a demi-virus. 
MM. Lagneau and Baumes seem inclined to this hypothesis, to 
which I shall again advert. Instead of a double virus, Carmichael 
contends for four kinds, which produce four different accidents. I 
repeat, the lesions which sometimes follow a suspicious connection, 
are sometimes of such different forms, and so varied in their re- 
sults, that we cannot be surprised that they should have been 
attributed to a different cause. But, thus far, we have arrived 
only at hypothesis, as we have studied under the influence of 
theory only. The experiments lately made to prove the inocula- 
bility of secondary accidents, or to show that the system may ar- 
rive at such a point of saturation as to resist all kinds of syphilitic 
action, or that chancre may be communicated to animals, have re- 
newed the questions, whether the virus is of different strength, 
whether it is modified by the blood, or in passing through the 
various organs, or from one individual to another, or from one 
kind of animal to another kind, and indeed if the virus is not 
changed by the different conditions of the organism with which it 
is brought into contact. Finally, it has been asked, are the differ- 
ent products due to the seed or to the soil. It has been justly 
maintained that differences, and these too very great, may arise 
from certain peculiarities of the organism created by a particular 
hygeine, by affections which preceded the invasion of the syphili- 
tic poison, by an immethodical treatment, administered without re- 
gard to time or quantity ; thus long privations, excesses, scrofula, 
scurvy, a badly-managed mercurial treatment, may exert an in- 
fluence on the progress and the form of a chancre. But, even among 
the numerous chancres produced by inoculation on the same indi- 
vidual, on the same organism, at short intervals, for the purpose 
of syphilising or saturating the individual, some have been ob- 
served to be very rapid in their march, others to remain a long 
time stationary, others, in fine, to become phagedenic, whilst others 
assumed the form of the real indurated, classic' chancre ; and what is 
worthy of note, these varieties have not always put on the charac- 
ter of the ulcers which furnished the matter for their inoculation. 
Thus just as the day would seem to dawn, darkness reappears, as 
has almost always been the case in syphilography, especially since 
it has made pretensions to positiveness. But, in this place, we can 
only glance at the questions. In studying the different forms of 



INTRODUCTION. 23 

syphilis, they will again come under our consideration. Then, 
whilst studying them in connection with cases, we may perhaps 
be permitted to have a glimpse at their solution. In investigating 
the nature of chancre, I shall particularly notice the connection of 
induration with constitutional infection, as this form of ulcer has 
been regarded as that which alone furnishes a contagious matter, 
or a specific virus.* 

Modes of Propagation. — Each virus, has, so to speak, its peculiar 
method of propagation. In the great majority of cases it depends 
upon sexual connection, and the genital organs are those most 
commonly affected. But debauchery has devised other forms of 
connection, other methods of contagion, involving other parts, as 
for example, the arms, the mouth, the lips. Lactation may like- 
wise favor contagion. The touche, operations with the fingers 
denuded of their cuticle, and wounds, have been the means of com- 
municating the virus. The more intimate and prolonged the con- 
nection the greater the risk of contagion ; it is from this cause that 
it is most frequently communicated by coitus and lactation. The 
chances will be still greater if there be a solution of continuity, a 
wound or laceration ; thus coitus with organs of disproportionate 
size is attended with more hazard than is the act under opposite 
circumstances, for the first-mentioned condition may be the cause 
of lacerations, which singularly facilitate the introduction of the 
virus ; this is the reason that, all things being equal, there is less 
risk in having connection with a woman who has born children, 
than with those who have not, particularly young females. So 
much for immediate contagion. The possibility mentioned, of 

* An impression generally prevails that the question of the plurality of poisons 
has been definitely settled in favor of the doctrine of a single virus. It is admitted, 
however, by M. Ricord (Lett, xviii. p. 143), that it is far from being yet solved, 
and in his xixth Letter (p. 145), he acknowledges that his experiments have failed 
to establish the doctrine. Mr. Acton recognizes the connection between the indu- 
rated chancre and the scaly eruption. {Treatise, 2d Amer. Ed. p. 285.) Mr. Egan is 
disposed to adopt with but slight modifications the views of Mr. Carmichael, and 
with the latter regards the experiments made by M. Ricord as lending a support 
to the doctrine of a plurality of poisons {op. cit. pp. 49, 52 ; and Carmichael's Clin. 
Led. p. 52). M. Ricord, indeed, states that in his experiments — "always per- 
formed on the patients themselves 1 — the ulceration produced by inoculation has 
invariably assumed the form and character of that with the inoculable matter." 
{Lett, xviii. p. 142.) Mr. Herbert Mayo, on the other hand, has reported a case in his 
work on Syphilis, p. 38, in which a clearly-marked underated chancre was produced 
upon the forearm of a patient, from the matter of a bubo following unindurated chan- 
cre. Again, whilst the experiments instituted in Dublin, furnish proof in favor of 
the doctrine of plurality of poisons (Egan, p. 54), those made at Turin (Sperino, on 
Syphilization, p. 300), tend decidedly to support the theory of a single virus! 

We may attribute the varieties, the characters of mildness or severity of primary 
sores, to constitutional influences, but of the nature of these influences avo are, and 
probably must long remain ignorant. Still, as observed by Mr. Porter, in his ad- 
mirable lectures on syphilis, published in the Dublin Medical Press for 1S46-7 (vid. 
Lect. viii.), " we are in this respect no worse off with syphilis than with many 
other affections; out of fifty patients, the subjects of operation, wo know not the 
few that may be seized with erysipelas ; out of a hundred wounded on the field of 
battle, we cannot point out the one or two that may subsequently die of tetanus ; 
neither can we explain the occurrence when it lias happened, otherwise than by 
saying it depended on the constitution." — G. C B. 

x (Case viii. p. 198, in his Treatise, is reported as an Inoculation on a healthy 
person. — G. C. B.) 



24 INTRODUCTION. 

preserving the virus for a long time, would lead us to suspect that 
of its transmissibility by mediate contagion, by means of objects 
on which it has been deposited, as, for example, the tubes or edges 
of glass in which it has been preserved. The stor}^ is familiar, of 
the young girl, who, to disguise herself, put on the breeches of a 
man, and thus contracted syphilis. A mask, the clothes of a per- 
son infected, the seats of a privy, it is said, have each been the 
means of conveying the disease. The authenticity of these cases, 
however, is not beyond reproach, and even if it were, it would 
furnish an argument in favor of the communicability of the second- 
ary disease. The sexual organs of the female may serve, so to 
speak, as a depot, from which the virus may be extracted. A 
man having connection with this female may contract the disease, 
and yet the woman herself escape infection. This has long been 
known. Thus, we read in Astruc (torn. II., p. 16): "A woman 
having connection with a man diseased, if repeating the act shortly 
afterwards with a sound man, may infect the latter, and yet her- 
self escape." Hernandez, with those who, in turn, have copied 
from him, makes use of this fact, and of this hypothesis, to support 
the doctrine that chancre alone can produce constitutional syphilis. 
For example, when a man contracts a chancre from a woman 
affected only with blennorrhagia, this woman must, according to 
them, have had a chancre larve ; if this cannot be found they 
invoke the aid of this doctrine of recently-deposited virus in the 
organs of the female, a virus which the man carries off to his own 
great detriment, but to the decided advantage of the woman, who 
thus escapes infection. Ever thus do conjectures come in to the 
support of hypothesis. 

Action of the Virus. — What is the modus operandi of the virus? 
To this question Fernel gave an answer, which, even at this day, 
is not without its value. He asserted that it acts like other poison- 
ous agents, producing a venomous effect, similar to that resulting 
from the sting of an asp, the bite of a mad dog, or from the small- 
pox virus. Chemistry and vitalism have furnished their exjDlana- 
tions, of which the exposition here would be of no real value. The 
solution which has met with most favor is that by Hunter ; accord- 
ing to him, the virus produces upon the living tissues a peculiar 
irritation, and determines a particular kind of inflammation, the 
special product of which is virulent pus. (I use here the words 
of the French translation). In another place Hunter adds : " The 
presence of inflammation is not necessary to the continuance of 
this peculiar action, for the poison is still formed long after the 
signs of inflammation have disappeared." Besides the specific 
action, he adds, "it acts as an irritant, then it excites new inflam- 
mations, the products of which are not contagious." This first 
supposition, which has been reproduced in our day for the purpose 
of concealing the mistakes of experimenters, has singularly ob- 
scured the questions concerning the nature of buboes and blen- 
norrhagia. 

Hunter admits the absorption of virus without any lesion of the 
surface to which it is applied, that is, without ulceration, without 



INTRODUCTION. 25 

previous inflammation ; this I call physiological absorption. After 
its absorption the virus passes into the blood, reaches every part 
of the organism, and may produce a double poisoning ; one, which 
is acute, with local reaction in the point contaminated, character- 
ized by what we call the primitive accident; the other, chronic, 
more profound, and maintained by the persistence of the first, and 
according to M. Cazenave, capable of being constantly aggravated 
by new infections until the state of cachexy is reached; this is 
characterized by the consecutive accidents. I have mentioned that 
some would restrict the terms primitive accidents to chancre ; thus 
implying that only through its surface can the syphilitic virus be 
absorbed. But chancre is not indispensable to infection. Indeed, 
as I have already advanced and as Hunter himself taught, the 
virus applied to certain points of the mucous membranes may 
readily reach the circulation, without any solution of continuity in 
the tegumentary surface ; the mucous membranes may easily be 
impregnated, and the absorption which it irresistibly exercises 
over most toxic agents which are presented to it in a liquid form, 
and over semi-fluid substances, is not confined to the syphilitic 
virus alone, since we see the virus of glanders, and that of variola, 
enter the blood from their simple application to sound surfaces. 
Physiological absorption does therefore occur. 

Once absorbed, the syphilitic virus may rest dormant, and 
remain a cause without effect. This is the period of incubation. 
When it becomes developed, independent of the primitive symp- 
toms, it is called primary or non-consecutive syphilis, (yerole d'em- 
blee.) In this case the general infection has preceded the appear- 
ance of the symptoms which have erroneously been called local. 
Thus, as M. Bousquet has proved, the vaccine pustle does not 
appear until the organism has been modified by the vaccine virus. 
MM. Lagneau, Baumes, de Castelnau, and Cazenave, are those, 
who, by their observations, have lately most contributed to estab- 
lish the fact of the incubation and the reality of the non-consecu- 
tive syphilis, {yerole d'emblee). When I treat of chancre I shall 
reproduce the facts which are peculiarly my own, and which 
harmonize with those of my confreres. Furthermore, analogy was 
already in favor of the incubation, for every virus possessing con- 
tagious properties lies dormant for awhile, and then reproduces 
itself; for a certain time the cause produces no effect, at least no 
perceptible effect. M. Kicord denies both the incubation and the 
non-consecutive syphilis, {yerole d'emblee). According to him, it is 
fundamentally and radically a local effect, that is produced by the 
virus in the part to which it is applied. And here this author 
rests upon experiment. Immediately after the lancet has placed 
the virus in contact with the living tissue, this virus acts, and then 
commences at once the evolution of the primary symptom, which 
is attended with redness, like that of a flea-bite, a pimple scarcely 
raised above the level of the skin, which uninterruptedly passes 
into the pustule and chancre. But the operation by which the 
skin has been divided and more or less irritated, a proceeding 
which places the pus in direct contact with the divided tissues, is 



26 INTRODUCTION". 

not the physiological act that applies the virus to the surface, and 
subjects this surface to a kind of friction, thus promoting absorp- 
tion, which remains physiological in proportion as the tissues are 
intact. Inoculation cannot justly be compared with coitus, except 
when a laceration occurs during the latter act. Then, indeed, 
there is immediately a pathological condition ; a local action is at 
once begun without incubation ; or, in other words, the general 
does not precede the local action, but they are simultaneous. 



OBSERVATION. 

The surest foundation of all theory and practice, is derived from 
the observation of natural phenomena ; but observation, always 
in pathology difficult, presents still greater difficulties when it re- 
lates to the accidents produced by the syphilitic virus. It must be 
acknowledged that it is rare to find patients whose statements can 
be believed, and certain facts escape the attention of the observer, 
either from his inability or want of capacity in observing them 
accurately. Let us first examine the causes of error dependent on 
the patient, after which we will notice those which may be attrib- 
uted to the observer. 

Patients attempt to deceive, or are themselves deceived. It is 
particularly the case in syphilis that we encounter deception on 
the part of the patient ; the reason of which is obvious. But this 
source of error has been singularly exaggerated, and when it is 
found that by the statements of the patient certain theories are 
compromised, the patients veracity is too readily doubted. Gene- 
rally, this disposition to deceive springs from interested motives, 
and not from any pleasure in the act. Now, the circumstances in 
which a patient can find it for his interest to conceal the truth, are 
not numerous ; it is generally, when they would repel the charge 
of having transmitted the disease, or when the manner in which 
they have become infected is regarded disgraceful or wounds their 
pride ; thus, the story of the nurse who accuses the nursling as 
the cause of her infection, that of the libertine, who denies having 
had connection or having been guilty of other libidinous acts, 
should be received with allowance. But patients of this class may 
still furnish us with useful information ; indeed, if we question 
them with care, to their affirmations they will add an exposition 
of a series of phenomena which have had their influence, and in 
this manner sometimes conduct us to the truth. M. Castelnau, 
who has written a work on the observation and interpreta- 
tion of facts in syphilography,* cites in support of this 
opinion, the following : 

A grandmother took her grandson to wean ; the child was in a 
wretched condition and had an eruption of pimples over the whole 
body, with excoriations in the mouth ; after some weeks it died, 
and two months after its death, the grandmother as well as her 

* Vid. Annates des maladies de lapeau et de la syphilis, No. 1. I have profited by 
this work. 



INTRODUCTION". 27 

daughter (the aunt of the child) became affected with a squamous 
syphilitic eruption.* 

Here, the only testimony we have in reference to the antece- 
dents of the case, was that of the two patients themselves ; how- 
ever, it was hardly possible to doubt their accuracy, as, besides 
their own assertions, we find a series of morbid phenomena which 
often occur in a natural order ; and the patients, as M. de Castel- 
nau remarks, could not have known how to arrange them so as to 
give an appearance of truth, consequently we must admit the veri- 
similitude of their own statements. 

Sometimes there exists another reason for believing the patient's 
own history of the case, as in the instance already quoted ; it is, 
that it will be very difficult to understand the nature of the affec- 
tion, if for their supposed falsehoods, we can substitute only ex- 
planations which are more or less improbable. In the case just 
noticed, the only other explanation left us, would be the existence 
of primitive symptoms in the aunt (the grandmother was about 70 
years of age, and it is not very probable that she was thus affect- 
ed) ; to establish the truth of this supposition, the aunt must have 
infected the child ; and the latter must have communicated prim- 
itive symptoms to its grandmother, without her knowledge of the 
fact (which is still more difficult to believe, as these symptoms 
must have shown themselves as evidence in certain parts, such as 
in the mouth, or in some other part of the face or hands) ; that 
this child had been so promptly affected by the virus as to die in 
two months, and this too while the grandmother and aunt were in 
excellent health ; that, in fine, these two women, of such opposite 
ages, had been attacked at the same time with constitutional symp- 
toms, although according to this hypothesis, the period of primi- 
tive infection must have been very different in the two cases. We 
see how similar explanations would be improbable, and how it 
would be more natural to believe the statements of the patients, 
especially when we know that they correspond with what many 
physicians have observed in cases where they have been able to fol- 
low, step by step, the development of all the phenomena. (Loc. cit.) 

At the same time, in approving the distrust with which those 
facts should be received, the authenticity of which rests solely on 
the patients honesty, I am far from justifying the conduct of 
those who reject them altogether, no matter what their source, 
provided they tend to conflict with their preconceived theories. 
Do we not, in the most serious affairs of life find that certainty is 
established by testimony which has no other warrant than the 
honesty of the witness ; why should we not in the same manner 
arrive at a scientific certainty ? Are there not men whose moral- 
ity is above suspicion, and whose testimony is equivalent to the 
most scientific demonstration ? "When Hourmann, observes M. 
de Castelnau, declared that he could not have contracted syphilis, 
except in the discharge of his duties as a physician, no one 
thought of doubting his veracity, and had any one dared so to do, 

* This case was communicated to the author by M. Alph. Robert, surgeon to 
the hospital Beaujon. 



23 INTRODUCTION. 

lie would have provoked but a just and universal feeling of in- 
dignation, among all who were acquainted with that virtuous man. 
I was the' colleague of Hourmann at the Lourcine, and I can but 
repeat the language of his pupil. Besides, we shall remark, that 
the svphilographers who are least disposed to admit moral proof, 
and who subject every female to suspicion, do not hesitate to in- 
voke the chastity of a husband when it is necessary to support 
their theory. 

"We will now consider the statements giveri by those patients 
who, without having any interest in so doing, yet deceive them- 
selves. Here, as in the study of other diseases, some of which 
present still greater obstacles'^ their investigation than syphilis, 
we are obliged to have recourse to the recollection of the patient 
for the causes, the first phenomena which appeared, and for the 
termination. It is evident, from the concordant results of differ- 
ent observers, that these may often lead us to the truth. Here, 
indirect means, artificial methods of arousing the patient's memory, 
every precaution, in fine, which is recommended in the best trea- 
tises on general pathology, must be made subservient to our pur- 
pose. Besides, there is a class of patients so intelligent, so careful 
of their persons, who are, indeed, such good observers, that their 
statements merit the greatest confidence, at least in the establish- 
ment of certain facts. Thus we shall see in examining the subject 
of incubation, that we do meet with patients capable of furnishing 
us with the most precise information on this point. Moreover, 
what is here required to be established ? Two capital circum- 
stances : 1st. The precise date of the coitus ; 2d. The time of the 
appearance of the first symptoms. A number of patients may 
very satisfactorily establish these circumstances. It is true that 
others require to be noted ; it is well also to take into account the 
habitual frequency of the coitus, for what is due to one of these 
acts may be attributed to another ; we must know if there was any 
preceding infection, and if any excesses have thrown the system 
into such a commotion as to disturb the natural order of the phe- 
nomena. But all this is not only possible, but sometimes unat- 
tended with difficulty, and we shall discover, in treating of incu- 
bation, that certain patients have been able, by their own state- 
ments, to furnish the elements essential to the solution of this 
important question. Still further, on this point, it is curious to 
observe these same systematists who deny a patient the necessary 
intelligence to establish a compromising fact, afterwards find this 
same patient quite competent to furnish details most difficult to be 
known, but which are favorable to their views. We shall have 
occasion to admire this inconsistency when we come to the chap- 
ter on the SypMlida. Some of these are not easily diagnosed ; we 
know that the syphilitic eruption appears after chancre and before 
exostosis, that it is, in fine, a secondary symptom. Xow, if in 
interrogating a patient, who has had these three symptoms, there 
is the least shadow of an eruption at the epoch required by their 
theory, his story is at once accepted, for the patient merits all con- 
fidence ; he is then intelligent, and his memory has not deceived 



INTRODUCTION. 29 

Mm. But if, on the other hand, he places the most strongly- 
marked eruption after the exostosis, for example, then no matter 
what the precision or the number of his facts, the patient is no 
longer intelligent, his memory fails him, he is incompetent to de- 
scribe the eruption on his skin, he is mistaken in its form, color, 
&c, &c. We see, then, that confidence is given or refused to a 
patient, not according to the degree of his intelligence, but accord- 
ing as his story is favorable or unfavorable to a particular theory. 
Would it not be better then to disregard in toto the testimony of 
the patient ? 

Away with all exaggeration, and let us try to distinguish the 
patient who can, from the one that cannot instruct us. We should 
not always judge of a patient's intelligence by the reply given to 
our first question, nor to our direct questions, but only after we 
have become better acquainted with them, and have subjected 
them to a cross-examination. In this manner certain patients 
may furnish us with valuable assistance in eliciting the truth. 
This, however, may be much more surely attained when we can 
see the patient at the outset of the disease, and can follow it 
through all its evolutions and note all the phenomena which it 
may present. Unfortunately, every observer does not feel the ne- 
cessity of collecting the minutest details ; indeed, some are content 
with the most prominent facts, which, in their estimation, are 
quite sufficient to establish the character of the disease. The 
young practitioner should let nothing escape his attention, not 
even the most trifling circumstances, for the absence of one of 
them, though it may not be essential, may prove a prize to those 
whose theory may be impaired by the facts of the case, and may 
afterwards unexpectedly compromise its authenticity forever. 

The ignorance and unskillfulness of the observer may be ad- 
mitted; but sometimes he is unjustly accused: thus, in the ques- 
tions to which blennorrhagia gives rise, it is all important that the 
facts in favor of, or against its specific character, should be col- 
lected with the greatest care ; no means of aiding our diagnosis 
should be neglected. In the case of a female, for example, not 
only the external parts of generation should be explored, not only 
should we press with the finger the urethra from behind forwards, 
expose the vagina with the speculum, explore it both when the 
instrument is introduced and when it is withdrawn, but we should 
bring into view the neck of the uterus, cleanse its mouth with a 
brush, and all this to see if we can discover no chancre to explain 
the specific nature of the symptoms which may occur, or to prove 
that they may arise, in the absence of chancre, from the inflamma- 
tion of a mucous membrane. It cannot be denied that formerly 
this physical examination was too much neglected, and even in 
our own day it is not always thoroughly made. But since Hun- 
ter duly warned us of the sources of error in his remarks on blen- 
norrhagia in the female, since the speculum has been so frequently 
employed, and especially since it was known that chancre might 
be hidden from our sight, our investigations have been more accu- 



SO INTRODUCTION. 

rate, and there is daily less cause for the reproaches which have 
been made against observers. 

To complete the subject, I will borrow the conclusions of M. de 
Castelnau, as contained in the first part of the work already 
quoted : 

1. Patients, with but few exceptions, do not attempt to deceive, 
except when they are impelled by interest, shame or fear. 2. 
Such cases are exceedingly rare in porportion to the number of 
persons affected with venereal disease. 3. Patients placed in such 
circumstances may still furnish us with reliable information, either 
because their testimony is corroborated by the fact of its conform- 
ing to the natural order of a series of pathological phenomena, or 
because we have no right to suspect their honesty. 4. There are 
patients who, by their intelligence and regard for their persons, 
may impart precise and sufficient details, respecting the diseases 
with which they are, or have been affected. 5. The physician 
may sometimes have the opportunity of witnessing all the morbid 
actions which constitute the disease in question, and then collect 
his facts without any doubt of their exactness, provided he has 
devoted to their study sufficient time and care.* 

Observation is therefore difficult, and when not beyond reproach, 
may be productive of error ; but there is still greater difficulty, in 
that operation of the mind by which we form our induction from 
the facts observed. There are facts, the connections of which are 
so simple, so evident, that their expression alone forms the axiom. 
But there are others which are not self-evident ; these must be 
subjected to our reason, before they can attain a scientific value. 
This process is attended with serious difficulties ; if the mind have 
not a proper bent, if it be biassed or imbued with some particular 
theory, error is sure to be the result. In this operation, we must, 
first of all, never lose sight of the facts themselves, and must guard 
against substituting suppositions in their place. Thus, in the ques- 
tion of the dependence of syphilitic blennorrhagia upon chancre, we 
should seek on all sides for the ulcer, and when found, note it 
particularly in interpreting our facts, but we should guard against 
supposing its existence, because a certain system positively re- 
quires that it shall figure in every case of the kind.f We must 

* Annates des maladies de la peau et de la syphilis. No. 1, p. 10. 

f The following remarkable instance of substituting supposition for facts is 
worthy of record. Dr. Richet, the family physician of a Parisian merchant, met 
M. Ricord in consultation. The case was that of a child, affected with syphilitic 
ulcerations in the ano-genital regions. Both parents and nurse being apparently 
perfectly sound, much perplexity was felt in deciding upon the origin of these 
ulcerations. The fact was mentioned, that ten clerks lodged in the same house, 
and perhaps one of these might be affected! Seizing upon this happy suggestion 
M. Ricord at once attributes the infection to the dandling of the child upon the 
naked hands of one of these clerks. M. Velpeau, in his communication to the 
Academy of Medicine, Sept. 21st, 1852, states that by accident he had learned from 
Dr. Richet, that this story of the posed clerk was a mere invention, having no 
other foundation than the circumstances above mentioned. In a letter subse- 
quently addressed to M. Velpeau, Dr. Richet observes: "Xo, positively, no, neither 
M. Ricord nor myself saw any such clerk!" M. Ricord's apology, as furnished in 
his communication to the Academy, Oct. 12th, 1852, is, that his report of the case 
was given from memory, which report in his Letters (xiii., p. lOi), is followed by 



INTRODUCTION. 31 

not reject certain facts, or deny the importance which they really 
possess, because they do not accord with those which have gener- 
ally been observed. Admit that they are exceptional, but if well 
established, nothing can destroy them, for a thousand negative 
facts cannot destroy one positive fact : this is an axiom that has 
been admitted since men have known the art of reasoning. Is 
more than one fact required to prove that wounds of the heart 
admit of recovery ? 

It is not inappropriate to notice in this place a part of the dis- 
course of M. Gilbert, in support of the doctrine of the transmissi- 
bility of the secondary accidents. The orator, wishing to show what 
errors may result from interpreting facts whilst swayed by the 
narrowing influence of theory, exclaims: "Thus, to limit primary 
syphilis to chancres, an urethral chancre in certain cases of blen- 
norrhagia must be supposed, and chancres with flat primary tubercles, 
or mucous pustules, the occurrence of primary buboes (d'emblee), 
be denied as well as the contagious character of certain vegetations, 
and we must metamorphose into chancres certain consecutive ulcer- 
ations of the tonsils, mouth or skin ; thus, must we torture and in- 
terpret the instances of the tardy appearance of the secondary ac- 
cidents of syphilis, and the cases in which some of these accidents 
have been transmitted, a transmission which has occurred more than 
once from the habitual and intimate relations which exist between 
the husband and the wife, the nurse and her nursling, and between 
the latter and other children under the same roof. The testimony 
of most credible witnesses must be rejected, and those who do not 
wish to explain clinical facts in the most difficult and irrational 
manner, must be accused of error or credulity. In a word, we 
must cull, prune, strike off, polish, and reduce to a certain measure 
marked in advance, all the elements of science that they may 
fit the famous square* without distorting its regular lines, or chang- 
ing its solidity. 

The difficulties in the way of observation, the qualities of mind, 
the time and patience required to render it complete, the sound- 
ness of judgment and intelligence necessary to a correct interpre- 
tation of facts, the doubts which cannot be removed, even by the 
union of all these qualities on the part of the observer, have some- 
some observations upon the tact and skill required to discover the true origin of 
the disease in these perplexing cases ! For all the details connected with this case 
the reader may consult the collection of Reports and Discussions, entitled " Be la 
Syphilization," <fcc, &c, pp. 304, 357, 378. To complete the history of this case we 
should add, that M. Ricord very modestly requests M. Velpeau, if he is not satisfied 
with his supposed cause (the poxed clerk), to furnish a more rational explanation. 
We read in the "Novum Organon" Aph. xix., lib. 1st, that "duos vice, sunt ad inqui- 
rendam et inveniendam veritatem." Whether the method adopted in the above 
instance be the "via vera" we leave for the reader to decide! We would also 
humbly submit whether M. Ricord himself has not furnished us with a more 
rational supposition of the true cause of the infection of this child, in his history 
of the case, (Letters xiii. p. 105,) where a child was born affected with syphilis, the 
legal parents of which, and the cavalry officer, the real father, were, to all appear- 
ance, perfectly sound, though the latter had been diseased ? — G-. C. B. 

* The orator here alludes to a confrere who has compared the system of M. Ri- 
cord to square. 

f Gazette des Hopitaux, Seance of 22d Sept. 1852. 



32 INTRODUCTION". 

times led syphilographers to prefer experiment, and to give to 
facts thus obtained, a preference over those acquired "by clinical 
observation. This leads us to the subject of experiment. 



EXPERIMENT. 

By this, we are not limited in our observations to facts naturally 
produced, but we provoke the manifestations of the disease, by 
trifling operations, by experiments. Hunter chiefly contributed 
to introduce experiment into syphilography, for the purpose of 
facilitating our investigations. Attempts have since been made 
to base upon it a doctrine, a treatment, a system. Now, we have 
already remarked, that a system is but an hypothesis. By experi- 
ment, a completely imaginary syphilis has been created. This was 
a natural consequence, for they knew not how to discriminate be- 
tween experiment purely physical, and that based on facts, partly 
physiological, partly pathological. If living nature had the uni- 
formity of that which is dead, the deductions from the experiments 
made upon it, would possess the same characters of certainty and 
simplicity, as do those which are entirely physical, and by them, 
laws might be deduced to establish a natural scientific system. 
But, as in the problems which we have to solve by experiment, 
the vital forces are concerned, as well as idiosyncrasies and morbid 
phenomena often very complex, the results must differ from those 
obtained in trying to solve the problems of physics or of chemistry. 
Besides, these results have not the character of simplicity which 
can prevent systematic interpretations, and the cavils of men of 
preconceived opinions. Indeed, opinions most opposite are daily 
expressed on the results of an inoculation. What I have related 
of Hernandez, has probably not been forgotten. Again, the pro- 
ceedings adopted for the purpose of provoking syphilitic manifes- 
tations, are on a very hmited scale. We shall soon discover, that 
those of nature are very diversified, and who can tell how numer- 
ous are the modes of propagating the disease ? Our proceedings, 
again, are very unlike those which we would imitate ; for example, 
there is a great difference between the insertion of the virus beneath 
the skin with the point of the lancet, and the contagion from coi- 
tus. The results must vary accordingly. We find, indeed, that 
the pus from a chancre which is inserted in our tissues by the 
operation, always produces a chancre, while that from a chancre 
the result of a coitus, sometimes produces a mucous piistule, 
sometimes a vegetation, sometimes a chancre. Certain accidents 
which are transmitted by coitus or other intimate connections, are 
not communicable by inoculation or any artificial proceedings. 

I am far, however, from rejecting experiment as a means of 
investigation ; I know too well the services which it may render ; 
but for myself it has no real value except when its results cor- 
respond with the facts observed in natural pathology. Again, 
experiment being at present greatly in vogue, and many physicians 
having neither time nor disposition to test the questions in syphil- 



INTRODUCTION. 33 

ography by tlie clinique, and by the rules of philosophy, prefer 
the demonstrations by the lancet. Unfortunately some of the most 
distinguished syphilographers, trusting to their reason and their 
clinical observations, condemn experiments as being immoral. 
They reason much, and reason very justly, but perform no experi- 
ments, hence their limited success contrasted with that of those 
who require actual demonstration. Other syphilographers, how- 
ever, relying chiefly on observation, despise not experiments, and 
believe, that when used within certain limits, they may prove use- 
ful to science, without infringing upon the laws of morality, 
properly understood. They experiment then more philosoph- 
ically, that is to say, without losing sight of clinical observation, 
they are no longer content to address the mind exclusively, 
but they speak to the senses, and it is chiefly by experimental 
means, indeed, that they successfully attack the errors of experi- 
ment. JSText come those who carry their experiments to extremes. 
Experiment is now no longer confined to the hands of M. Ricord 
and his pupils ; it is made in a different spirit, and by methods 
more varied, whence the results which I shall soon mention. 

I speak not of the dangers of experiment, and my aversion to 
everything not directly scientific must have been observed. The 
dangers which it is my duty here to notice, as I write for instruc- 
tion, are of another kind. I have stated, in another place, that 
nothing is more injurious to study, to true progress, than to invest 
forms with certainty, and particularly to designate those methods 
of exploration which may sometimes conduct us to it by the name 
of certainty, as these means are far from being infallible, especially 
if they are trusted to alone, and are not based upon observation. 
Delusions are thus prepared for the student, and disappointments 
for the practitioner. I think, therefore, that in speaking of the 
immutable laws of experiment, M. Ricord is guilty of error, and 
exposes his pupils, who take him at his word, to disappointments 
innumerable. Those laws only are immutable which are not 
made : they are from all eternity ; by them was chaos dissipated ; 
his laws, those which he has created, if possible, would cause it to 
reappear. Again, by experiment we produce pathological facts, 
the interpretation of which is as difficult as that of natural facts ; 
the proof lies in the want of unanimity, and the doubts which have 
arisen from the experiments lately performed to test the doctrine 
of syphilization, and which we shall soon proceed to notice. 



INOCULATION. 

The experiments instituted for the purpose of producing the 
various forms of syphilis, have chiefly consisted in inserting the 
virus or the supposed virulent humor, according to the method 
adopted in vaccination. The lancet has been charged with the 
matter which we would apply to the living tissues, and by it the 
skin is punctured. Sometimes incisions have been practiced, 
some scrape the skin so as to remove the epidermis ; some make 

3 



34 INTRODUCTION. 

scarifications ; and in some instances an infected part has been 
fixed against a sound part ; thus, Luna-Calderon scraped the skin 
before he applied the virulent pas in his experiments for the pre- 
vention of syphilis ; M. Auzias removed only the epidermis of 
animals with the curved scissors ; Wallace often denuded the skin 
with a blister, and dressed the wound with charpie saturated with 
the pus of a pustule. This proceeding has been repeated by M. 
Bouley, who has thus inocujated with the matter from a pustule, 
and produced a second syphilitic infection in a woman whose sys- 
tem had already been completely contaminated with the disease. 
I have performed the same experiment with success. Waller scar- 
ified healthy individuals, and dressed the little wounds with the 
blood from a syphilitic patient, or, with the pus from mucous pus- 
tules, and in both cases he succeeded in . producing constitutional 
syphilis. ■ M. Yelpeau fixed the prepuce upon a portion of a glans 
affected with vegetations, and in this way produced a vegetation 
on the part. The methods may be ever so diversified, yet can 
they never reach the same variety as the natural proceedings, and 
particularly is it true, that the latter can never be completely im- 
itated. This is the reason why experiments often fail. 

Again, two conditions are indispensable to the success of an in- 
oculation : 1. A virulent matter ; 2. An organism, with a certain 
susceptibility to the action of the virus. There must be good seed, 
and a soil favorable to its germination. Isow these two conditions 
may be wanting, and nothing can previously indicate their ab- 
sence ; therefore, inoculation cannot be infallible, as some have 
pretended ; it can be but a means of investigation, and never a 
practical measure, and a system which rests solely upon it, should 
fall. M. Eicord has pretended by inoculation to distinguish affec- 
tions apparently similar ; to establish the difference between the 
primitive and consecutive accidents, to aid the cause of justice, 
and, in fine, to establish a classification, a system ; further, still he 
maintains that by the same proceeding, he has proved that syphi- 
lis is confined to the human system. Now, to effect all this, it is 
necessary both in a practical and scientific point of view, to estab- 
lish the infallibility of inoculation, to give to it the character of a 
test. M. Eicord believes in this infaUibility, and has had the bold- 
ness to proclaim the equality of the human species before a chan- 
cre, before that ulceration which, in his opinion, is the only inocu- 
lable form of syphilis. Now it has been proved, that there are 
chancres, real chancres, which do not contain inoculable matter, 
whilst there are true consecutive accidents which may be inoculat- 
ed ; it has been demonstrated that the most virulent pus produces 
no effect on certain individuals, that there are, in fine, some per- 
sons who from accident or idiosyncracy are insusceptible of any 
syphilitic infections. To give, therefore, to inoculation the value 
of a chemical test is a most unfortunate idea, for in a theoretical 
point of view, it leads to deception, and as regards practice to cruel 
disappointments ; whilst in legal medicine, which is of serious im- 
portance, it may divert justice. True re-agents have a negative 
and a positive value ; an infusion of turmeric when changed to a 



INTRODUCTION. 35 

red color, shows the presence of an acid ; and thus furnishes the 
certainty of its existence ; but if it be not changed to red, then the 
absence of the acid is positively indicated. Do these observations 
apply to inoculation ? No. If, therefore, inoculation produces a 
positive result, we must say to justice — yes, the accused is affected 
with syphilis, he is guilty ; but if inoculation produces no effect, 
we cannot say — the person is not infected, he is innocent ; we can- 
not say it, for it has been proved, that this person might have one 
of the most infectious of all chancres, which nevertheless, under 
certain circumstances, would not be inoculable. I must remark, 
however, that I have made a concession in accepting the positive 
results of inoculation as weighty evidence in the cause of justice. 
I must add, that these positive results may be differently inter- 
preted, since they are pathological facts, which are not simple, and 
which may possess different characters, for we know that there is 
no characteristic pustule, the first effect of the inoculation of chan- 
cre. In fact, there never was a characteristic pustule, and it will 
be shown, in treating of the first period of chancre, that this ulcer- 
ation may be established at once (d'emblee), and that if it is pre- 
ceded by another lesion, this lesion is sometimes a pustule, some- 
times a vesicle, sometimes a bulla. Still further, when chancres 
were produced on the ape, M. Eicord declared that he could not 
there recognize a form of syphilis, unless such chancres were fol- 
lowed by consecutive accidents ! We see then what becomes of in- 
oculation, even in the opinion of M. Kicord, since, according to 
his own views, the existence of chancre is not proved until con- 
secutive symptoms shall have supervened.* 

* Were a practitioner required for medico-legal purposes to give a positive test 
of syphilis, could he comply with such a requisition ? In corroboration of our 
author's remarks in reference to the insufficiency of inoculation, we may quote the 
numerous experiments made by Dr. Egan, at the Westmoreland Lock Hospital, 
Dublin. In his recently-published and excellent work " On Syphilitic Diseases," p. 
2*7, he remarks that he was not unfrequently foiled in obtaining the characteristic 
pustule, 1 " although, from the appearance of the primary sore, and the subsequent 
effects upon the constitution, conclusive evidence was afforded of the contaminating 
influence of the disease." He states that every possible care and attention were 
bestowed upon these experiments, and the matter was always taken before the 
reparative process had commenced. JSTo one acquainted with Mr. Egan, can, for a 
moment, doubt his competency or credibility. Mr. Langston Parker, in his 
"Modern Treatment of Syphilitic Diseases" (2d Ed. 1845, p. 26,) very happily 
expresses the true value of inoculation as a test, as follows : " In the present state 
of the science, all we can say is, that certain ulcers, the result of sexual intercourse, 
and not distinguishable by their external characters from other ulcers equally the 
result of sexual intercourse, yield a characteristic pustule by inoculation ; but the 
ulcers which do not yield the characteristic pustule, are equally liable to be fol- 
lowed by secondary symptoms, and are equally benefited, under many circum- 
stances, by mercury." In alluding to Mr. Egan's experiments we should have 
observed that those made with the matter of buboes led. to the same result, viz., a 
frequent failure in producing the characteristic pustule. (Vide op. cit. p. '22.) 

The physical characters of the primary ulcer are so diversified that no absolute 
diagnosis can be formed from them alone. Although M. Eicord (Lett. xxi. p. 162) 
states that the physiognomy of the primary sore is generally so expressive that we 
may recognize it at a glance, yet in Letter viii. p. 140, as well as in his Treatise, 
(Uh American Ed. p. 48), he is Very decided as to the impossibility of forming a 
correct opinion from the physical characters alone. For the most complete account, 

1 In discussing the question as to the existence of a blennorrliagic virus, we shall 
prove, even by M. Ricord himself, that there is no characteristic pustule. — G. C. B. 



36 INTRODUCTION". 



INOCULATION OF ANIMALS. 



Hunter, Turnbull, MM. Eicord, Cullerier, de Castelnau, and 
other experimenters have tried in vain, they assert, to inoculate 
animals with syphilis ; hence they have concluded that the inocu- 
lable principle of syphilis is peculiar to man and cannot be trans- 
mitted to the brute. M. Eicord has reduced this proposition to a 
formula, and more than all others, has labored to defend it, jelying 
upon Hunter's experiments and his own, which, he asserts, have 
been very numerous. Now, as regards Hunter's experiments, we 
quote his own words : "In whatever manner it arose, it certainly 
began in the human race, as we know of no other animal that is 
capable of being infected with this poison." In another place, 
Hunter adds : " We know of no other animal that is susceptible 
of the venereal irritation, for repeated trials have shown that it is 
impossible to give it to a dog, a bitch, or an ass." He then subjoins 
the following note : "I have repeatedly soaked lint in matter from 
a gonorrhoea, chancre and bubo, and introduced it into the vagina 
of bitches and of asses and under the prepuce of dogs, without pro- 
ducing any effect. I have also made incisions and introduced it 
under the skin, and it has produced only a common sore. I have 
made the same experiments upon asses, with the same result."* 

It is evident that these experiments are neither numerous nor 
varied, and that the operation here referred to by Hunter, is not 
of a very decided character. 

M. Eicord asserts that he has performed numerous experiments. 
I think that we shall search in vain for a detailed account of these 
experiments. In his writings, I have been able to find but the 
following passage : a T have tried, with syphilitic pus, procured in 
every possible condition, to inoculate dogs, cats, rabbits, guinea pigs, 
and pigeons, which are said to be soon destroyed by the absorp- 
tion of the syphilitic poison. In no instance, notwithstanding the 
variety of the experiments, has it been possible to transmit the 
disease." We might, without seeming too sceptical, demand some 
details as regards the proceedings followed, in order to compare 
them with those which at the present time have produced positive 
results, for animals have been inoculated with success. We 
might, without appearing too exacting, inquire if, in this enuncia- 
tion there is that on which a law, or even a proposition, under a 

however, of the varieties presented by the external characters of a primary sore, 
we would refer the reader to the admirable lectures of Mr. S. Lane, in the London 
Lancet, for 1842, vol. xi. p. 49*7. Mr. Porter proposed, as the one undeniable test 
of syphilis, the capability of the individual supposed to be affected, of transmitting 
the disease to the foetus in -utero, (Led. on Syphilis, Dub. Med. Press, leb. 24th, 1847, 
p. 114;) but' in a note on the same page he adds: "As if to destroy the possibility 
of ever establishing a test of syphilis, I have, this day, (Aug. 25th, 1846,) been 
informed, by an authority on which I place implicit reliance, of the case of a woman 
having twins ; one of the infants was deeply infected, and the other apparently 
quite sound and healthy." The value of mercury, as a test, has long since been 
settled, and need not occupy our time. Are we not, therefore, justified in assuming 
that a positive test of syphilis remains to be discovered? — G. C. B. 
* Hunter, (by Babington, Am. Ed. pp. 20, 31.) 



INTRODUCTION. 37 

formula somewhat absolute, could be based. We shall see that 
M. Eicord, iu admitting more recently the possibility of inoculat- 
ing animals with chancre, himself annuls this law, and in so doing 
makes a breach in his own system. 

M. Cullerier has also made numerous experiments, which he 
has been particular to relate. These experiments were performed 
in part with the assistance even of M. Auzias, and M. Cullerier 
says that he has failed. For my part, I think that my honorable 
colleague has not always failed. But these experiments are de- 
tailed and published, and the public can judge for themselves. 
Almost all are negative. 

M. Auzias himself has met with numerous failures; but, in 
certain cases, he has succeeded, as have MM. Langlebert and 
Diday. The experiments of this last physician, those of M. Rob- 
ert de Weltz, leave no doubt of the possibility of transmitting 
chancre to the brute ; and chancre, according to M. Eicord, is the 
essence of primary syphilis. M. Langlebert, in describing his 
experiments to show the efficacy of a prophylactic, positively 
asserts : "I scraped the left arm with a lancet which had been 
dipped in the same pus, the virulence of which I had proved by 
inoculating a monkey which had a perfectly developed chancre.* 
I have seen, on the arm of M. Eobert de Weltz, a well-marked 
chancre, which was inoculated by M. Eicord himself, who took 
the pus from a chancre on a monkey. M. Eobert was already 
inoculated with a chancre from pus derived from the same source. 
After these results, M. Eicord presented the hardy German physi- 
cian to the students who attend his course, and in their presence 
declared, " that the experiments of M. Auzias Turenne had fully 
succeeded, and that the two ulcerations with which I was affected 
were true chancres." These are the very wards of M. Eobert de 
Weltz himself, f M. Diday also experimented; he inoculated a 
cat with pus from a chancre of the second generation on the same 
animal, having applied it to the prepuce ; and from this proceed- 
ing resulted a very serious phagedenic chancre. With the pus 
from chancre, M. Diday inoculated two rabbits on the ear, with 
success ; one of these chancres became indurated.^ The experi- 
ments of M. Diday, which are fully detailed in the journal quoted, 
leave no room for doubt. 

The following is the proceeding of M. Auzias, as described by 
himself. This physician chose the central part of the pavilion of 
the ear, being that possessed of the greatest vitality. " My place 
of election was the mastoid surface of the pavilion of the ear. The 
principal reasons for so doing were the following : 

"1, The part is easy of management ; 2, the animal cannot lick 
it; 3, it does not see our manipulations, consequently it labors 
under no fear; 4, the cellular tissue of this part being loose and 
serous, we may easily perceive induration, when it assumes a de- 

* A Letter addressed to the Academy of Medicine, July 22, 1851. 
f Vide De VInoculation de la Syphilis aux Animaux, (extrdit de la Gazette Medi- 
cale, ann. 1850.) 

t Vide Gazette Medicale de Paris, Dec. 22, 1851. 



38 INTRODUCTION". 

cided character. The induration, in my opinion, is the rule, and 
not the exception. This is a point, the explanation of which I 
reserve for further consideration. Two instruments only are re- 
quired for this operation. 

" 1. A spatula, or some flat instrument, to take up the pus, and 
to apply it to the part to be inoculated. 

" 2. Small scissors curved on the flat surface, and pointed. 

" I much prefer this instrument to the lancet. The puncture of 
the lancet excites in the animal a sudden movement, which it is 
important for the precision of the operation, and the security of 
the operator to avoid. The animal, on the contrary, appears not 
to feel the action of the scissors, which, besides, we are always 
able to control. 

"If the animal is troublesome, I have it held, while I shave the 
part selected, to the extent required. The excision of the hair 
with the curved scissors is a still more simple proceeding. The 
following is the operation : 

" With the point of the scissors, I remove the epidermis to the 
extent of two-fifths of a line. The more superficial the incision, 
provided the epidermis is excised, the better the operation suc- 
ceeds. If blood is drawn, I consider its success compromised, 
and I repeat the operation in another place. Sometimes I make 
several sections at certain distances from each other. 

" On the denuded portion of the dermis, I deposit the pus from 
a chancre, either pure, or mixed with a small quantity of saliva. 

"3. For a minute I keep the part moist, either by means of the 
pus or saliva ; at the same time I rub with a blunt instrument the 
periphery of the part. 

" In the next place, I abandon the animal to itself. 

"I never fear mixing the pus with saliva, whenever it is not 
sufficiently abundant to carry it away. The important point is, 
that a certain degree of humidity prevents the coagulation of the 
fluids, by which the virus would become imprisoned* 

" The clay after this trifling operation, a pimple appears at the 
point inoculated. On the next a vesicle, which, in twenty -four hours, 
becomes converted into a pustule. These phenomena, perfectly 
regular, require more or less time for their production. Finally, 
the perfection of this evolution is a chancre covered with a crust 
or scab. This chancre becomes round, excavated, and increases 
in extent : a pus, abundant in quantity and of a deep color, raises 
the scab, and the epidermis to a certain distance from the scab. 
The adjoining skin is hot, red, and tumefied. The abundance of 
the pus, which occupies and irritates the parts, induces the animal 
to scratch itself; and this fluid passes under the edges of the scab, 
which it raises and detaches. As soon as a certain quantity has 
escaped, the parts are rendered less tense. The edges of the scab 
become glued again, or if it has been carried away, a new scab is 
formed. The epidermis retracts, and shrinks concentrically to the 
chancre, and is detached by pellicles. The chancre then progresses 
for several days, and the order of the latter phenomena (I mean 
those which follow the pustule) is repeated several times. The 



INTRODUCTION". 39 

ulceration is finally arretted ; it gradually diminishes in size, and 
at length disappears, having constantly retained the physiognomy 
and characteristics of chancre of the skin." 

M. Eicord has entertained several opinions on the results of 
inoculation in animals, as he has upon almost all the important 
questions in syphilography. At first he denied the results, then 
he admitted and proclaimed in full clinique the success of M. 
Auzias. But soon retracing his steps, and finding the theory of 
transplantation already made by M. Cullerier, he seizes upon it, 
without claiming aught of the invention, showing for once the 
good sense of my colleague. According to this hypothesis, the 
ulceration produced on the animal was not specific ; it was a wound 
like any other in which virulent pus is deposited ; only it is a 
soil, in which it cannot germinate ; it may germinate when trans- 
planted into another soil, such as that furnished by the human 
system. I should add, that I have myself heard M. Eicord aban- 
don this theory, an act which has greatly amused M. Malgaigne. 
Now, indeed, M. Eicord admits chancre in the brute, that is, pri- 
mary syphilis, but not the consecutive 'disease. Thus, then, we 
behold a law abrogated even by the legislator himself." 

We may here insert with propriety part of a discourse pro- 
nounced by M. Malgaigne before the Academy of Medicine dur- 
ing the discussion of the subject of syphilization, a discourse 
which, as has been remarked, formed an event. M. Malgaigne 
produced a profound sensation, especially when he attacked the 
system of M. Eicord. The friendship which for twenty years had 
united these academicians, and the well-merited eulogies which, 
on several occasions, had been mutually pronounced on each 
other, were known. M. Malgaigne could not therefore be sus- 
pected of anything like hostile feelings. Now, listen to the words 
of this eloquent professor : " Often had I seen the doctrine of M. 
Eicord vigorously attacked ; and often these attacks had revived 
my doubts ; never had I seen him conquered, forced to beat a 
retreat, still less to surrender. That time, gentlemen, has arrived. 
One of the doctrinal points of M. Eicord is that syphilis belongs 
exclusively to man, that it cannot be communicated to animals. 
I will not go back to the first experiments of M. Auzias : for a 
long time their results were denied ; I myself plead guilty to a 
part of this injustice. On another occasion I have said, When 
we have produced chancres in the monkey, ivhat then? Such 
prejudice, gentlemen, is to be regretted; a fact is a fact, though it 
may remain for a long time unapplied ; but most frequently this 
apparent inutility but proves our ignorance of its relations. For 
myself, I have already stated, this fact is henceforth incontestable. 
In listening to the discourse of M. Eicord, I coulcl not discover 

* We are informed by M. Sperino, in his recently -published work (1S53) on 
" Syphilization" p. 27, that M. Sigmund, of Vienna, has successfully inoculated 
warm-blooded animals, and that in the dog, rabbit, and horse, the primary acci- 
dents were followed by a syphilitic eruption. On the same page, he gives the 
details of a case in which he himself successfully inoculated the horse. This 
question would, therefore, seem to be definitely settled. — G. C. B. 



40 



INTRODUCTION. 



whether lie admitted or rejected it. (M. Eicord: I admit it) I 
am tlien most happy to find myself once 'more in unison with him. 
But if he admits it, should he not spare those sarcastics attacks by 
the aid of which he seems to struggle against his own true con- 
victions, and to cease to bring forward still that strange theory of 
transplantation, which, in eccentricity surely, does not yield to 
any among the advocates of syphilization. 

" This fact,, so puerile in appearance, was the first breach in the 
system of M. Eicord. For the first time, he was conquered, and, 
mark it well, he now found himself attacked with the same weapon 
which had so often enabled him to conquer, viz., experiment I" 



SYPHILIZATION. 

I shall not repeat the declamations which have been made 
against syphilization. I will not defend it. I shall attempt only 
to ascertain whether, from all this agitation, from all the experi- 
ments to which syphilization has given rise, some facts have not 
been elicited, some light been shed, by which the advance of 
science may be promoted. • 

According to M. Auzias, " Syphilization is a condition of the 
organism, in which, owing to a kind of saturation, the phenomena 
of syphilis can no longer be evolved. T&is same experimenter 
employs the word syphilisme to denote the capability of being 
syphilized ; we may say, for example, of an individual, that the 
degree of syphilism which he possesses, is in proportion to the 
facility with which he may be syphilized." I copy literally from 
M. Auzias. 

Syphilization is produced by inoculating a certain number of 
chancres, which perform the part of the vaccine pustule ; they 
vaccinate them, that is, they produce an exemption from syphilis. 
Starting from this hypothesis, chancres have been given to sound 
individuals with a prophylactic end, to exempt them from the 
liability, not only of primitive, but consecutive accidents. Then 
the syphilizers, having imagined that " the syphilitic virus was the 
best remedy against the action of the syphilitic virus," they have 
proposed to syphilize, that is, to inoculate chancres with a thera- 
peutic end, to cure s} T philis, both primitive and consecutive. This 
double application of syphilization has been particularly defended 
by MM. Auzias and Sperino. M. Marchal confines himself to a 
recommendation of curative syphilization. 

M. Diday has invented another vaccination. Believing in the 
unity of syphilis, he would subject it to the same laws which gov- 
ern variola, rubeola, &c, by which a person can be affected but 
once during life, and the surgeon of Lyons has inoculated not 
only chancre, but the blood of individuals in the last stages of 
syphilis, or rather, who are laboring under a constitutional condi- 
tion which will no longer tolerate the syphilitic action. The first 
system, that of the inoculation of chancre, has roused the pas- 
sions and the indignation of learned societies and the press. The 






INTRODUCTION. 41 

second, that of vaccination -with the blood of a patient affected 
with tertiary symptoms, has been regarded as the dream of an 
honest man, and has been passed over in silence.* Even before 
the sixteenth century, the consoling idea was entertained of the 
disappearance of syphilis, by the exhaustion of the virus, or the 
saturation of the human race. Thus the universal syphilization 
which this good M. Auzias would now realize, was long since 
announced to us. In the work of Astruc we may find this opin- 
ion often expressed: "The venereal disease, having had a begin- 
ning, should have an end." It is known that Astruc was an 
advocate of the modern origin of syphilis. "What is regarded as 
being favorable to this author's opinion is, that time diminishes 
the virulence of syphilis, which at present is more benign than it 
was formerly. Its effects being really less deplorable than at the 
end of the fifteenth century, hopes were therefore indulged of its 
complete extinction. But, to share in this hope, and to adopt the 
hypothesis of Astruc, we must also accept his erroneous opinion 
on the origin of the disease ; for, if it be really of ancient origin, 
the question changes, as it has lost nothing of its force in descend- 
ing towards us ; on the contrary, at certain epochs it has assumed 
an aggravated form, particularly during the close of the fifteenth 
century. 

After the idea of universal saturation, followed that of the satu- 
ration of certain nations ; and I will soon show that the human 
race may be both partially and generally saturated. Swediaur 
among modern writers has most clearly expressed this idea of the 
saturation or syphilization of certain nations. Thus, according to 
his views, the virus imported into a country yet uncontaminated, 
whatever its climate may be, produces at first very violent effects 
upon its population; effects which gradually diminish, because 
the people become more or less saturated : the disease loses its 
violence. But, he justly observes, if a foreign people invade a 
country in progress of syphilization, its victory is dearly purchased. 
Thus the Portuguese became gradually syphilized by long famili- 
arity with the disease, and yet they transmitted it to the English 
invaders in all its virulence. 

These facts when not closely examined, and whilst yet in their 
rough state, seem favorable to the modern doctrine of syphiliza- 
tion. But the question here arises, are there countries free from 
syphilis. The varieties produced by difference of climate and of 
regimen, in the manifestations of the disease, will hereafter be no- 
ticed. Thus, an army in a foreign land always suffers more than 
the natives, from the diseases of the country, and generally it 
finds less assistance, is less acquainted with the means of protec- 
tion, and the best modes of treatment ; hence the aggravation of 
the symptoms, by which attention is most directed to the strangers. 
The natives, on the other hand, more easily escape observation. 
The treatment followed, and the malady itself exhibiting less vir- 
ulence in them, excite but little notice. 

* Vide my Lettres sur les Inoculations Syphilitiques. 



42 INTRODUCTION. 

However, I would not absolutely deny the syphilization even 
of a people, for analogy, although remote, sanctions its ad- 
mission. There are natural facts respecting the saturation of soils, 
which may daily be observed ; thus, seed committed to the same 
soil for two successive years begins to degenerate ; if it be not 
changed, if the soil be not allowed to rest, the results are hybrid 
and even naught, for the seed will not germinate. But let the soil 
rest, and in the language of the agriculturist, let it lie fallow for 
some years, then we shall find that the same seed which the soil 
refused, germinates better than before. 

It may be the same with the organism, which becomes insensi- 
ble to a poison, to which as it were it has been accustomed, and 
which, after a certain repose, will not be the less susceptible to the 
influence of the same poison. We find, therefore, that saturation 
considered in the most general manner, presents characters which 
are neither definite, nor absolute. As the soil which permits 
not the germination of one kind of grain, shows itself favorable 
to that of another, it is possible that the organism insensible 
to one virus or one quality of virus, may be affected by another 
kind. Thus, if there were several kinds of virus, the question of 
syphilization would be much less complicated, much less obscure, 
than it is according to the hypothesis of a single virus, which leaves 
it in very great perplexity. 

Instead of inveighing furiously against the advocates of syphi- 
lization, I have observed, with their hypotheses in view, in order 
that I might decide coolly and philosophically. Now, a fact 
which in my opinion is unquestionable, is the syphilization of a 
certain sphere ; in fine, local syphilization. Thus, 1 have seen a 
very active chancre on the summit of the glans secreting pus which 
was diffused over the rest of the organ, bathing the whole pre- 
puce, which was much elongated, and yet these parts were not in- 
oculated. This same pus imbrued the penis and the scrotum, 
which resisted its action. But one day there appeared on the su- 
perior and internal part of the thigh, a well-marked chancre 
which furnished an inoculable pus. It was produced by the end 
of the penis which several times rested in contact with this part 
of the thigh. Thus, the same pus which on the genital organs 
was inert, had inoculated the thigh. The genital sphere was here 
syphilized, in other words, it was under the influence of a vital re- 
action, which resisted the extension of the ulceration on the sum- 
mit of the glans, as well as the production of other chancres. It 
was the same prophylactic power that prevented M. Sperino from 
prolonging the ulcerative stage of a chancre by the application for 
six days of virulent pus, because it was in the reparative stage. 
This kind of local syphilization must, in all cases, be admitted, 
otherwise every chancre would increase indefinitely, it would 
know no limits. The more decided this local syphilization, the 
more limited the chancre ; phagedenic ulceration shows the ab- 
sence in a certain sphere of this syphilization. But let it not be 
supposed, on this account, that syphilization is permanent. These 
same parts, this same sphere, which in the patient above men- 



IXTROfcUCTTOX. 43 

tioned could not be inoculated by the pus of the chancre on the 
summit of the gians, became so one month afterwards from an 
impure coitus. This patient, in fact, left the hospital cured of his 
first chancre ; but, in one month, after a single connection, re- 
turned with three chancres on the prepuce, of which one was three 
times the size of that of the former one on the glans. Here we find 
a part at one time effectually resisting the action of the virus with 
which it was in contact, and yet at a later period, becoming inocu- 
lated with several chancres from a single coitus ! This case fur- 
nishes one of the strongest proofs of the possibility of local syphi- 
lization, but at the same time, a proof of the short duration of 
the immunity produced by it. The case proves also that second 
chancres may be more numerous, and larger than the first, con- 
trary to the opinion which has been entertained, that the ulcera- 
tion of chancre becomes more limited in extent, in proportion to 
the frequency of its occurrence. 

Had these facts in local syphilization been known by those ex- 
perimenters who have inoculated subjects that presented them- 
selves as individuals who had been syphilized, they would have 
applied their lancets to some point remote from the sphere already 
inoculated, and would thus have avoided some mistakes to which 
they have appeared very sensitive. 

It will be perceived, that by greatly multiplying chancres in 
several different regions, we may arrive at a general syphilization. 
This effect may even be obtained by inoculations less numerous 
and limited to one or two regions ; thus, it is evident that M. La- 
val * was completely syphilized by inoculations practised on the 
superior extremities. 

Those who have followed the discussions in the Academy on 
syphilization, know that the case of M. Laval has been differently 
interpreted. This young confrere has served for the battle-field 
between M. Auzias and M. Eicord. More than two hundred spec- 
tators have witnessed this contest ; it has been fought, as is always 
agreeable to M. Eicord, coram populo, and yet we know not who 
has been the victor ! But of one thing I am perfectly convinced, 
viz. that M. Laval has been inoculated by our honorable colleague, 
M. Gosselin, and that too with pus which readily produced chan- 
cres on a woman at the Lourcine affected with syphilis, whom 
they proposed to treat by syphilization. Now, this same pus re- 
mained impotent, inert, when it was inserted beneath the skin of 
M. Laval, and this too, after three inoculations. This fact was 
communicated to me by M. Gosselin himself, and I believe it as 
fully as though I myself had performed the experiment ; for, be- 
sides his knowledge and integrity, this colleague cannot be accused 
of being a partisan of syphilization, since the only part which he 
took in the debates, was to give publicity to a fact which is unfa- 
vorable to the system. Indeed, M. Gosselin has published the 
case of this same woman on whom he succeeded in inoculating 

* M. Laval, now a doctor in Medicine, was syphilized whilst he was a student, 
and he defended a Thesis on the subject of syphilization. 



44 IJSTRODUCTIOK 

chancres, and he has shown that her disease only increased during 
these inoculations. 

It maj be answered, that if the fact of the patient's system being 
already infected is unfavorable to curative syphilization ; that of 
M. Laval is decidedly in favor of prophylactic syphilization. But a 
distinction must be made between temporary and permanent im- 
munity. For example, this same confrere, M. Laval, who with im- 
punity defied the lancet of MM. Ricord, Gosselin, and other experi- 
menters, has at length been lately inoculated with success, at least 
M. Ricord has so stated to the whole Academy. And here I have 
no hesitation in believing M. Ricord, for the fact which he has re- 
lated, was under my own observation. Perhaps what I have men- 
tioned respecting the saturation of the soil, when the same seed has 
several times been sown upon it, may be recollected ; in that case 
it produces only hybrids, and ends by refusing all germination. 
But, after a certain period of repose, this same soil is no less favor- 
able to the germination of the seed, than it was before inert. I be- 
lieve therefore that the system of M. Laval had been placed in the 
same condition as the soil of which T have spoken : after the labors 
of M. Auzias with the lancet, it yielded only hybrid products, 
pustules which never became chancres ; then it became totaly bar- 
ren. But after a certain period of repose, M. Laval's system be- 
came like that of most men, susceptible to the action of the virus. 
I have said, like that of most men, and not of all, because in cer- 
tain subjects there may exist an immunity, natural or acquired, as 
is the case with other morbid poisons. 

The fact, that persons are often exposed with impunity to syph- 
ilitic contagion, is known, though in a vague manner, to every prac- 
titioner. I will here particularize one which at the time made 
a strong impression on my mind. 

A man who acted a certain part in the revolutions of 1830 and 
1848 (he is known to many of my confreres who mingled in the de- 
bate on syphilization), had a remarkably fine and robust constitu- 
tion. He was a great libertine, and not at all particular with what 
females he had connection. He never, however, became infected, 
as was frequently the case with his friends who had intercourse 
with the same woman, for I was often called upon to treat them. 
Having became acquainted with the fact, and knowing well this 
brazen man, as he was called, it happened that I attended two 
flower-girls with whom he had had habitual connection, which 
girls had inoculated other persons. They both had chancres. I 
sought no further proof, and believed in this man's immunity. 
However, he made his boasts that he could not catch the pox ; 
some one offered to give it to him provided that he would consent 
to submit to a trifling experiment, a proposition which he at once 
accepted ; two inoculations were made on his arm with pus taken 
from a chancre then in a progressive state, but without effect, abso- 
lutely without any result whatever. 

Here then was a natural immunity resembling that produced in 
M. Laval, and still more complete, for Mr. Laval was subjected 
only to experimental inoculation, whilst this person was exposed to 



INTRODUCTION". 45 

physiological inoculation, to true contagion. But time may work 
a change in this man's constitution, or from circumstances impos- 
sible now to be appreciated, he may become as vulnerable as M. 
Laval. 

Thus the fact of a temporary immunity, established by observa- 
tion, and by experiment, is of importance, especially from its bearing 
on that system in syphilography which is based upon inoculation. 

We may here with propriety insert an extract from the discourse 
of M. Malgaigne pronounced before the Academy of Medicine, on 
the question of syphilization. M. Malgaigne, alluding to the natu- 
ral immunity possessed by certain individuals, proceeds : " Now, 
can this immunity be artificially produced? Henceforth, the reply 
to this question cannot be in the negative ; and I am surprised 
that the orators on the part of the commission, should have thrown 
so entirely into the shade, a fact of such capital importance. You 
remember the case of the patient of M. Marchal (de Calvi); he 
presented this condition of immunity. How rapidly M. Eicord 
passed over this subject ! The patient of M. Telaschi, so often re- 
ferred to, had acquired the same immunity : neither M. Eicord nor 
M. Begin have noticed it ; their attention was called to it by M. de 
Castelnau, who, however, can never be ranked among the parti- 
sans of s} r philization. And then there is the case of M. Laval. 
"We shall come to that in a moment gentlemen, but I must reply 
to a previous objection. 

" Supposing the fact to be well demonstrated, after all what 
consequence is it ? Those who propose such a question cannot be 
very thoroughly acquainted with the actual state of the science on 
this subject. I have briefly pointed out some of the most important 
doctrines of M. Eicord ; for the most part, gentlemen, they rest at a 
greater or less distance, on a common basis, that is, inoculation limit- 
ed to the pus of chancre, and the impossibility of resisting the action 
of this pus. Here are no circumlocutions, no doubtful expressions. 
T/ie pus of chancre, says M. Eicord, is inevitably inoculable. The 
matter of variola and vaccina finds those who absolutely resist its 
action, the pus of chancre none. This doctrine he has admirably 
expressed by a kind of aphorism so forcible in its conciseness. All 
men are equal before chancre. It was, as you will observe, a kind 
of joolitical constitution which he imposed upon syphilis, it was his 
constitutional chart. 

" Now, behold, on a certain day, he is startled by a revolution- 
ary fact, which suddently breaks down this promised equality, 
rends his chart, and subjects his patients to other laws. I can well 
understand then gentlemen, why this legislator has resisted this 
new fact : I appreciate his warlike ardor ; I comprehend why he 
would have his battle of Saltzbach, and why before this tribunal 
he has attempted, to use his own words, a new campaign in Italy. 
This resistance, moreover, was not shown during the discussion 
which really drew forth this fact. At the first announcement of 
the threatening immunity, he entered his protest, and the amphi- 
theatre of the hopital du Midi re-echoed his defiance, his challenges. 
Besides, it was for its verification that he provoked his adversaries. 



46 INTRODUCTION. 

'I wait,' lie remarked, 'that they may show me an individual 
syphilized and insusceptible of the action of the virus, who will 
go before the clinique of the hopital du Midi, and defy me in camp 
with weapons of my choice /' 

" This challenge was repeated on the 12th August by the Union 
Medicate. On the 22d Aug. M. Auzias accepted it ; on the 23d 
Sept. M. Kicord declared that he was waiting. The Editor of the 
Union Medicate exclaimed : Facts, facts ! give us, rather than theo- 
ries ! And then, gentlemen, then the 4th November M. Kicord 
proclaimed that the experiments had been commenced, and that 
the result would be communicated to the journal. Search it well, 
and this communication cannot be found. Eight days afterwards 
M. Kicord presented M. L. to the Surgical Society, and on the 18th 
November to the Academy of Medicine. But not one word about 
the experiments. On the 20th, M. Latour gave the case of M. L. 
as the only public and authentic experiment then known. As if 
to break this silence, on the 9th December M. Marchal wrote to 
the Gazette des Hopitaux that M. Laval had presented himself to M. 
Ricord, that the latter had made on him, at two different localities, seven 
punctures, and had inserted three hinds of pus, of undoubted virulence, 
without any residts. M. Kicord made no reply ; the Union Medicate 
lisped not a word. You are aware that the report of the commit- 
tee maintained the same silence. 

"For myself, gentlemen, this silence amounts to a defeat, and 
et, I should have preferred a frank and public acknowledgment, 
or this reason I have provoked explanations upon this point. 
They have come from various sources ; I will not dwell upon them ; 
I wish to speak of M. Kicord. And what has he told us ? That 
he produced on M. Laval an ecthymatous pustule so well marked 
as to require no counter proof, and that the other inoculations 
which had failed on the person syphilized, had also failed on those 
from whom the matter was taken. No other details. M. Kicord 
declared that he should be wanting in dignity to say more. This 
course, gentlemen, does not satisfy me. What connection can 
there be between M. Kicord's dignity and the details of an experi- 
ment? In all, from his own admission, on his own ground, in 
camp, and with, weapons of his choice, he succeeded but once in 
seven inoculations. But other patients were equally refractory, 
thus showing that his pus was not good. "Who could have be- 
lieved, gentlemen, that M. Kicord, after so solemn a defiance, in 
his vast field, would be under the necessity of saying that he could 
not find good pus ? But, at last, an inoculation has succeeded. 
Succeeded ! when you yourself, sir, have not made the counter- 
proof which on all occasions you declare to be indispensable, in 
order to know that the pus produced can be re-inoculated. For 
my own part, gentlemen, I consider this acquired immunity in 
certain persons as proved, demonstrated, and incontestable. If 
M. Kicord still has doubts upon the subject, I pledge myself to fur- 
nish him with all the elements required for conviction. If the 
committee consent to witness the experiments, I pledge my honor 
to bring forward a young man who professes to be syphilized, and 



£ 



INTRODUCTION. 47 

who defies M. Eicord to produce on him a single atom of inocula- 
ble pus. M. Eicord shall take his precautions ; and if he fails the 
first time, he can try again ; my subject declares his readiness to 
submit to twelve hundred inoculations, and even more if it be re- 
quired. Now I trust that no person, will deny the facts without 
subjecting it to the test. Here, then, is a truth of capital import- 
ance elicited by this discussion. You have read the excellent 
treatise of M. Eicord on syphilitic inoculation ; you have seen the 
valuable results which he has obtained in diagnosis, prognosis, and 
therapeutics ; you will recall to mind his nice deductions in legal 
medicine ; all these are shaken, all totter when chancre is no longer 
fatally inoculable ; diagnosis becomes uncertain, prognosis decep- 
tive, and treatment doubtful ; above all, can legal medicine, which 
requires absolute certainty, longer dare to trust, as heretofore, to 
inoculation ? These remarks apply directly to primary syphilis 
only ; there is reason to apprehend that the system is soon to suffer 
another check as regards constitutional syphilis.""* 

This part of M. Malgaigne's discourse produced a profound sen- 
sation. M. Castelnau, who, in the Gazette des JEdjoitaux, had 
warmly defended M. Eicord, in this contest with the partisans of 
syphilization, in the same journal addressed a letter to M. Mai-, 
gaigne, in which we find the following passage, showing some 
modification in his views: "Yes, you have had reason to insist 
upon the fact that the pus of chancre is not fatally inoculable, even 
when it is contagious, and that certain individuals, either from ac- 
cident or idiosyncrasy, are not susceptible of its action ; you had 
reason to proclaim boldly that this is a fact of capital importance, 
subverting, as it does, the ingenious scaffolding of our illustrious 
confrere, M. Eicord." (Gazette des Hojpitaux, Aug. 26th, 1852.) 
This is the result of the efforts made to establish an imaginary sys- 
tem ; the object could not be accomplished, but another resting 
upon a false basis has been overthrown. It is not the first instance 
in which the object sought has not been found, but in its place 
something of more value has been discovered. 

Again, to justify prophylactic syphilization, we must first es- 
tablish the unity of the syphilitic virus, and the necessity of sub- 
jecting the organism to this saturation ; it is necessary, in fine, that 
the analogy between syphilis and variola should be complete. 
Now, in the second part of this work, we shall find the experiment- 
al and logical proof of the possibility of several attacks of consti- 
tutional syphilis. Of this we may become convinced by what has 
been said of the temporary saturation of the system, and of the 
susceptibility which it again acquires of being infected by the dis- 
ease. Thus, as I have already stated, tl^e person whom we would 
syphilize may really have the malady that we would give him, 
and that which he might otherwise contract. That syphilis will 
inevitably follow contagion is far from being established. On the 
contrary, it has been found that the half of those most exposed 
escape, a fact observed by Parent Duchatelet. It would therefore 

* Bulletin de V Academic de Medecine, t. xvii. p. 1046. 



48 



INTRODUCTION. 



be irrational and inhuman to give positively to an individual a 
disease to protect him from that to which he is not fatally con- 
demned. Prophylactic syphilization, therefore, is an irrational 
project. 

As to curative syphilization, I have earefully examined the ar- 
guments adduced pro et contra, and in my estimation they are yet 
insufficient to decide the question. For example, M. Telaschi 
treated a phagedenic chancre, which, it is asserted, had been ag- 
gravated by cauterization. It was of thirty-six days' duration. 
Nineteen inoculations were made, yet the chancre continued to 
progress. An eruption and osteocopes supervened. M. Sperino, 
a surgeon of note, and well versed in this subject, directed a re- 
newal of the inoculations. In the course of eight days forty-three 
of these were made. On the twelfth day, the progress of the erup- 
tion was arrested, and the pains had diminished. On the seven- 
teenth, the pain had increased ; the chancre began to cicatrize, and 
in less than two months the cure was complete. This is the re- 
port of the case as presented by the partisans of syphilization. 
Observe, it is that of a chancre which in two months became cica- 
trized, of a syphilide which was arrested, and of osteocopes which 
were mitigated, all of which might have occurred in the complete 
absence of treatment. I do not regard this, with M. Eicord, as a 
lamentable case, but it certainly deserves not to be called admira- 
ble, as some advocates of syphilization would seem to imagine. 
That furnished by M. Marchal (de Calvi) of a patient who had 
been for a long time diseased, and who had taken iodide of potas- 
sium and mercury without benefit, was one of tubercular ulcera- 
tion of the tongue, was improved in four or five days by inocula- 
tion, and seems to me worthy of attention. But the occurrence of 
spontaneous and even rapid cures after the discontinuance of all 
treatment, greatly modifies the importance of this case. It should 
be observed, besides, that this patient was not cured, as there was 
a relapse. 

In another part of this work, we have recorded the remarkable 
case of a barber, affected with a consecutive ulceration, which 
involved nearly the whole external surface of the inferior extremity. 
Every effort was made to arrest and to cure this painful and 
debilitating ulcer. Combinations of mercury, iodine and iron, cod 
liver oil, and different topical applications, were tried in vain. It 
was then proposed to syphilize this patient. I replied that he had 
sufficiently syphilized himself, and I applied narrow bands of 
emplastrum, "de vigo" plasters, folding them one over another, as 
in the method of dressing par occlusion, and in less than a month 
this patient was cured. This fortunate result may fairly be attrib- 
uted to the absorption, by a large surface, of the mercury con- 
tained in the plaster.* But perhaps it may be said that in this 
instance the reparative stage of the ulcer had arrived, that the 
system was in a condition to react effectively, and that nature 
alone had effected a cure. Had I syphilized this jjatient he would 

* Something similar to the Emp. ammon. cum hydrarg. — G. C. B. 



INTRODUCTION. 49 

have been cured ; it may be a little less rapidly, but still lie would 
have been cured; and then! — From what I have stated the 
reader may surmise my views on the so-called lamentable cases of 
syphilization, which cases may have been unfortunate, independent 
of syphilization. Thus M. Laval, whose name is so frequently 
mentioned in this work, this German physician, who has been 
pronounced the victim of syphilization, became infected from the 
matter of a consecutive accident in one of his confreres. After the 
inoculation a papular eruption appeared, which he desired to be 
treated by the successive inoculations of several varieties of 
chancrous pus. In this manner he produced on himself an infinite 
number of chancres. The progress of his disease, however, was 
not arrested, as would probably have been the case had he not 
been inoculated, and especially if he had followed no plan of treat- 
ment. The facts yet produced by this prophylactic or curative 
syphilization are far from entitling it to a place in medical science, 
but may be of real value in assisting to destroy a system resting 
on a false basis.* 



TRANSMISSIBILITY OF SECONDARY ACCIDENTS. 

This question, viewed in connection with public or private 
hygiene, is one of vast importance; it presents itself daily in 
ordinary practice, and not unfrequently in courts of justice. Ee- 
garcled purely in its scientific bearings, it is one of the most interest- 
ing in etiology. 

The earlier writers on syphilis believed that the disease might 
be communicated by everything which surrounds, and by all that 
is within man; thus, they supposed that the atmosphere, every 
emanation from the body, the breath, perspiration, the natural or 
morbid secretions, the blood, in fine that anything might serve as 
a vehicle for the poison. Syphilis was regarded as an epidemic, 
and capable of being propagated in every possible manner. With 
such views, they must have admitted for facts fictions, sometimes 
absurd, as for example, that it might be communicated through 
the grates of a confessional, by the perfume of a bouquet, and a 
minister was actually put to death, because, knowing that he had 
the disease, he had dared, nevertheless, to breathe into the ear of 
the king. 

The absurdity of such notions was early discovered, and it was 
exposed even by Fernel ; at a later period they were attacked, and 

* The Treatise of M. Sperino, to which we have already alluded, contains the 
results of some 94 cases of syphilization, performed for curative purposes, which 
results this surgeon regards as highly favorable to the practice. Permission having 
been granted by the Government to institute a series of experiments on this subject, 
M. Sperino, who is at the head of the venereal hospital at Turin, immediately 
availed himself of the means at his disposal, and in his elaborate -work, the reader 
interested in this matter will find copious details. Fifty-three of these 94 eases 
were primary syphilis, the remainder being constitutional syphilis. Fifty of the 
former, and twenty-five of the latter cases are reported as cured! But we must 
refer the reader to the work itself, and will only add that syphilization, as yet, has 
found but few if any advocates either in Great Britain or this country. — G. 0. 13. 



50 INTRODUCTION". 

iii our own day tne truth has been revealed. Not only has the 
idea of an epidemic and fantastic contagion been abandoned, but 
some have gone so far as to admit but one mode of propagation, 
but one vehicle of the poison, viz. the pns of chancre. Thus, the 
atmosphere, the human breath, and perspiration are very properly 
no longer regarded as the mediums of propagating the poison, but 
with these some would include the blood, the normal secretions, 
as well as those that are morbid, except pus, a question which is 
by no means settled, as Hunter and his disciples would seem to 
believe. According to M. Kicord, who has given an absolute 
character to the doctrines of his master, infection can occur only 
from the matter secreted by a chancre, which matter alone is the 
medium of the virus ; the latter can enter the system only by a 
chancre, and its infecting properties do not reach beyond the first 
lymphatic ganglion in direct relation with the chancrous surface. 
Beyond this ganglion, the virus may still injuriously affect the 
individual inoculated, producing secondary symptoms, such as 
pustules and syphilitic ulcers over his body, but can do no harm 
to others, as it no longer exists as a contagious agent. Of course, 
if but one individual could be found, whose chancres had cicatrized, 
but who was still covered with ulcers and pustules, who, in fine, 
was completely saturated with syphilis, the disease would die with 
him, he could not communicate it to those thrown into contact the 
most frequent, intimate and prolonged, and the syphilization of the 
world would then be complete! This is the latest doctrine 
advanced by the disciples of Hunter. But a grave and incontest- 
able fact here presents itself, it is that of the infection of the child 
in its mother's womb, a fact admitted by all syphilographers. It is 
unquestionable, that a woman, having neither chancre nor bubo, 
but that form of syphilis only, which it is asserted, can no longer 
be infectious, may give birth to syphilitic children, which may 
infect their nurses, whilst the latter, in turn, may communicate the 
disease to their families. This is the same syphilis that should 
have disappeared with the cicatrization of the last chancre, but 
which here reappears and recommences its ravages. The principle 
of contagion may therefore exist elsewhere than in the pus of 
chancre, and other than the primary ulceration. ' 

Analogy could not fail to seize upon a fact so widely known, and 
should have led to its admission, since, even after the cicatrization 
of a chancre, the system may still contain an infectious principle 
capable of being transmitted to another being ; by multiplying the 
relations, diversifying the experiments, and employing different 
humors, we may expect to prove the transmissibility of syphilitic 
accidents independent of chancre or its products. Observation 
here confirming analogy should have anticipated the results of 
experiment, and, doubtless, in any other epoch than the present, 
would have rendered it unnecessary, for the instances of the infec- 
tion of the nurse by the child, which is seldom affected with other 
than secondary accidents, are exceedingly numerous, and MM. 
Bouchacourt and Bardinet de Limoges, have recently reported cases 
with details so precise as to leave no room for doubt. Again, the 



INTRODUCTION. 51 

transmissibility of the mucous tubercle by means of intimate rela- 
tions and contact is generally admitted. On this subject the works 
of MM. Lagneau, Baumes, Cazenave, Gibert, and of other unpreju- 
diced observers, may be consulted. Among the patients which 
come under the practitioner's care, opportunities will occur, if the 
two be treated together, of seeing the mucous tubercle in both, in 
its different stages of origin, seat, and isolation from other acci- 
dents, thus removing all doubts of its contagious character. In 
another place I shall appeal to M. Eicord himself. We shall find 
that he admits the infection of the nurse by the child,* and the 
contagiousness of the mucous tubercle in the adult, but, as he 
expresses himself in his Treatise, it is by some incomprehensible 
vital process.f He admits contagion only, that is, physiological 
inoculation, and still denies the fact of experimental inoculation. 

As it is chiefly with contagion itself that we are now concerned, 
and not with this or that method of it, in my opinion the question 
is settled by M. Eicord's own admission, and for this reason, I am 
the more astonished that he still persists in opposing my views. 
Thus, the clinical fact is known even to my opponent, that sec- 
ondary accidents are contagious, since M. Eicord acknowledges 
the contagion of the mucous tubercle, an accident which he classes 
among those regarded by him as secondary. It remained, how- 
ever, to establish the fact by experiment, a matter of importance 
in an age so given to experiment. I cannot too often repeat, that 
for those whose minds have been trained to observation and legit- 
imate induction, the question needed no experimental proof. But 
for the school, especially as it was not long ago, we were compelled 
to descend to experiment. I have experimented, and for the first 
time in France, have succeeded in inoculating the pustule of sec- 
ondary ecthyma. 

At the simple announcement of this result, whilst the case was 
still in my cartons, the attacks commenced, and they were directed 
chiefly against the experimenter. I saw the position in which 
they would place me, and for a long time I submitted in silence, 
knowing that sooner or later the end would come, and I continued 
to observe, to experiment. During this period, men of indepen- 
dent minds, whose attention had been awakened to the subject, 
also observed and experimented ; they were attacked in the same 
manner. In the body of this work may be found, indeed, an ac- 
count of observations made in Paris, and in Germany, observa- 
tions which accord entirely with my own. These formed the basis 
of an essay which I read to the surgical society, and which drew 
forth a discussion. At a later period, a German physician was 
presented to the Academy of Medicine, who had inoculated him- 
self with a consecutive affection ; this gave rise to another discuss- 
ion, the results of which, in the estimation of every unprejudiced 
person, must have been a condemnation of the doctrines I op- 
pose. 

* Vid. section of this work on Infantile $ uphills, p. 
f Vid. p. 182, of M. Eicord's Treatise. 



52 INTRODUCTION. 

Objections have been made to the small number of facts which 
experimentally prove the transmissibility of the secondary acci- 
dents. It has been stated, especially by M. Eicord, that if these 
accidents can be inoculated once, they can always be inoculated. 
Now, it is not correct to say that the facts of inoculation are rare. 
A different impression will follow the perusal of the writings of 
"Wallace, reprinted in the Annates des Maladies de la peau et de la 
syphilis, as well as of the contents of this book. These facts, as 
my opponents have lately been forced to admit, are rare and ex- 
ceptional, only when they chance to possess great weight in this 
question. It is well known, indeed, that all the negative facts in 
the world cannot destroy one positive fact. M. Diday, whom M. 
Eicord persists in citing as a partisan of his doctrine, referring 
to the experiments by which Wallace proved the transmissibihty 
of the secondary accidents, remarks : " These cases are not very 
numerous, but more are not required to shake the security which 
reposes on negative facts."* f 

M. Eicord, who had asserted before the Surgical Society, that if 
the secondary accidents could once be inoculated, they could al- 
ways be inoculated, no longer repeats this argument before the 
Academy of Medicine, because, during the interval which passed 
between the two discussions, the question was settled experiment- 
ally, since which he has been silent on this point. 

It has been proved, to my certain knowledge, that chancre, even 
when inoculated according to the most approved method, and by 
the most skilful experimenter, is not always reproduced. Chan- 
cre, then, can be transmitted only under certain conditions. Now, 
the same observations should apply to the secondary accidents. 
However, as the principal conditions which are favorable to the 
success of the inoculation of a chancre are known, — witness the 
great number of experiments already made for this purpose — those 
which affect that of the secondary accidents have been less studied, 
and are almost completely unknown. Further, the secondary af- 
fection, which should be especially inoculable, is that which is of a 
purulent character ; now, this is represented by ecthyma, which is 
rare. This form of cutaneous disease consists of several varieties ; 
there is one which appears shortly after the chancre is healed ; it 
resembles varicella ; the pustules have a thin scab, which, in fall- 
ing, leave no ulceration, or that but trifling. I am almost certain 
that this variety is more easily inoculable than that which appears 
at a later period, when there exists an affection of the bones ; the 
number of pustules is then very limited ; they are to be found 
principally on the extremities, the legs ; they are very large, and 

* Gazette Medicale, Oct. 6, 1849. We are also indebted to M. Diday for the pub- 
lication of the most conclusive fact concerning the inoculation of chancre in the 
brute, a fact denied by M. Ricord. 

f Dr. Skae successfully inoculated four out of thirty -six cases of mucous tuber- 
cles. — Xorthern Journal of Medicine, April 1844, or Cormack's Lond. and Ed. Month- 
ly Journal, July 1844, p. 620. M. Sperino {op. cit. p. 502), refers to other suc- 
cessful inoculations of secondary accidents not alluded to by our author ; they 
were made by MM. Sigmund, of Vienna, and Gamberino and Galligo, of Italy. — 
G. C. B. 



INTRODUCTION. 53 

tlieir thick scab, in falling, leaves a deep ulcer. Thus, the condi- 
tions required for the inoculation of the secondary affections being 
almost completely unknown, and these affections which are inocu- 
lable, being themselves rare, the experiments on the subject, un- 
like those on chancre, being also of recent date, the success obtain- 
ed in the one case forms no criterion by which we may judge of 
that in the other. 

I am satisfied that certain non -syphilitic affections, which are re- 
garded as not admitting of inoculation, would become so, could 
we but seize on the right moment when they contain inoculable 
matter. Thus, at present, when attempts have been made to inoc- 
ulate chancre, the ichorous discharge from the ulcer has been 
used, or the detritus of the cancerous mass. But are these really 
the parts inoculable ? Is it not rather the cancer-cell at a certain 
period, whilst yet recent, that should be employed ? The success 
obtained by Langenbeck, leads me to believe that that is the ele- 
ment required. This experimenter took fresh cells from a cancer 
yet warm, removed from the humerus, and introducnd these cells 
into the blood vessels of a dog. Cancerous tumors in the lungs 
were the result. 

* To return to the consecutive syphilitic affection, I would re- 
mark, that in France, inoculation has succeeded only after the 
method adopted for that of chancre, that is, with the lancet as used 
in vaccination. We know that the manner of applying the agent may 
exercise a great influence upon its effects. I have already shown, 
that for the inoculation of the brute with chancre, the ordinary 
proceeding is insufficient, since M. Auzias was obliged to resort to 
another already described. Aside even from the inoculation of 
syphilis, substances are found which remain inert after the ordinary 
method of inoculation, and yet which produce very marked re- 
sults when applied in another manner. Tartar emetic ointment 
is one of these ; I have tried to inoculate it without success ; while 
by frictions I have succeeded in producing pustules. The mucous 
tubercle which is so readily communicated by prolonged and repeat- 
ed coition and by suckling, is not inoculable by a simple puncture of 
the lancet ; but if a blister be previously applied, and if we dress the 
denuded dermis with charpie steeped in the pus of the pustule, in 
fine, if we adopt the method of Wallace, as M. Boulay has done, 
as I have done, then the inoculation will succeed. It is also prob- 
able, that a simple puncture of the lancet dipped in syphilitic 
blood, would not produce positive results. But if, as has been 
done by Waller (de Prague), we scarify the skin, if with a par- 
ticular instrument we introduce infected blood into each trifling 
incision, and if the whole is covered with the same blood, we shall 
have strong reasons to expect the same success which Waller ob- 
tained. Besides the arguments which I have mentioned and op- 
posed, others have been raised less and less scientific, in propor- 
tion as my adversaries have lost ground. At first, the cases left 

* Smidt, Jahrbuechcr ; t. xrv., quoted in the Encyclopedic Anatomiq u\ t. ix. p. 
279. 



54 IXTRODUCTIOK 

something still to be desired on the score of authenticity ; the diag- 
noses of the inoculated affection had not been made ; instead of 
taking matter from a secondary disease, it had been taken from a 
chancre ; then followed insinuations against the credulity, the dis- 
honesty of the observers, &c. In all desperate causes the same 
course is adopted. With regard to the experimenters, I will cite 
the names of Wallace and Waller, who were at the head of an ex- 
tensive venereal service ; MM. Bouley and Eichet, who experi- 
mented at the Lourcine, and M. Cazenave, the author of a Treatise 
on the syphilida, whose experiments were made at the hospital 
St. Louis. The names of the pupils in Paris who reported these 
cases, are MM. Pellagot, Schneph, Lafargue, Piberet, Eossen, Co- 
det, Dubreuil, and Dumenil, all of whom are distinguished internes. 
£Tow I entreat those who are investigating this subject, and who 
are desirous of coming to some conclusion, to peruse these reports, 
together with those of the internes mentioned, and of my confreres^ all 
of which show the transmissibility of syphilis otherwise than by the 
pus of chancre, (these cases are particularly noticed in the chapters 
on mucous tubercles, the syphilida, and exostosis ;) then let them 
examine those presented by the opponents of this doctrine, which 
may be found in the Treatise of M. Eicord. Having duly con- 
sidered the arguments offered by both parties, they may then ob- 
tain a satisfactory decision. They will be surprised at two circum- 
stances in the work just quoted, first, the small number of the ex- 
periments, their want of connection, and the absence of all details ; 
second, the limited time after the experiments that the patients re- 
mained under observation. Constant allusion is made to the very 
numerous negative experiments, as was the case with those relating 
to the inoculation of animals. Now go to their sources, and see 
what number they can offer ! Of course we refer to authentic 
sources, to books and writings, not to private conversations. M. 
Yelpeau has exposed the value of the facts brought forward in op- 
position, in a discourse which must long be regarded as a remarkable 
specimen of annihilating criticism ; they have been reduced to the 
character of simple assertions, in some instances of no importance 
whatever. Waller has likewise noticed the brief period during 
which the subjects inoculated with secondary accidents were 
watched ; and the incubation being occasionally quite prolonged, as 
in the instances reported by Wallace and the physician of Prague, 
M. Eicord may have regarded as failures some really successful 
inoculations. In this case, he would not be the first who has un- 
consciously succeeded. I am certain that this has happened to 
another experimenter with whom I am acquainted. It may have 
been observed, that when I alluded to the fact of incubation after 
the inoculation of secondary accidents, I did not speak in decided 
terms, for it may be absent, or rather a small pustule may at first 
be developed, which miscarries, and yet some time afterwards the 
genuine pustule may appear. In this case, the first pustule seems 
to be but traumatic, whilst the other is a specific effect. Further, 
since I started this question of the transmissibility of the second- 
ary accidents, M. Eicord has not seriously examined the subject, 



INTRODUCTION". 55 

and he has even rejected the facts brought forward without an ex- 
amination. At this, however, I should not feel wounded, since 
he has been guilty of the same conduct towards his own pupils 
and friends. In the discussion on tubercular affections of the testis, 
M. Malgaigne proclaimed in full tribune, that M. Eicord com- 
menced by rejecting the observations of his brethren, and that he 
treated in the same manner those of his pupils made under his 
own eyes. Even those made by himself have shared the same fate, 
when opposed to his theories.* If M. Eicord thus treats obser- 
vations relating to tubercular affections of the testis, what would 
he not do with those which endanger the safety of his system ! 
Examine the discourses and writings of M. Eicord in reply to the 
arguments and facts adduced not only by myself, but by every 
orator in the Academy, his answer is always the same ; it is always 
what we call petitio principii; for supposing that to be demonstrated 
which is precisely the point in question, and his opinion upon this 
point being unchangeable, he responds by the question, that is, 
by his opinion. The whole, in fine, may thus be briefly expressed ; 
chancre alone is inoculable. Now this is the point in dispute, and 
the contrary we aim by facts to prove. This has long been a fa- 
vorite method of reasoning with M. Eicord, but with no bad inten- 
tions. It is thus noticed in the Thesis of M. Helot, formerly an 
interne of the hopital du Midi : 

" My dear master, like others who are wedded to some favorite doctrine you have 
established the value of inoculation on the petitio principii. For such I write not, 
but for those who seek the truth, and I believe that I have here furnished them 
with the elements of conviction, drawn from analogy, observation, and experi- 
ence." Our author has clearly demonstrated that secondary accidents are trans- 
missible, yet as important medico-legal questions not unfrequently arise in con- 
nection with this subject, it may be satisfactory to the young practitioner to know 
that this doctrine is defended by the following eminent British and American 
authorities, viz., Sir Astley Cooper, Lectures on Surgery, by Tyrrel, Am. ed., p. 497 ; 
Mr. Liston, Elements of Surgery, by Dr. Gross, p. 205 ; Mr. Colles, On Venereal, p. 
263 ; Mr. Wallace On Venereal, p. 335 ; Mr. Hey, Med. Chir. Transactions, vol. 7th, 
1830, p. 541 ; Jesse Foot, On Venereal, p. 402 ; Herbert Mayo, On Syphilis, pp. 
122, 123; Sir Benjamin Brodie, Lecture in Lond. Lancet, Feb. 1844, p. 677; Mr. 
Babington, Notes to Hunter, Am. ed., p. 321 ; Mr. Lawrence, Lectures on Surgery, 
Lond. Med. Gazette, March, 1830, pp. 806, 807 ; Mr. Porter, Lectures on Syphilis, 
Dub. Med. Press, Feb. 17th, 1847, pp. 99 ; Mr. Whitehead, Illustrations of Trans- 
mitted Syphilis ; Samuel A. Lane, Lectures on Syphilis, Lond. Lancet, May 2Sth, 
1842, p. 294; Mr. Bacot, On Syphilis, p. 252; Mr. Carmichael, Clin. Lectures on 
Ven. Diseases, p. 51 ; Langston Parker, Modem Treatment of Syphilitic Diseases, 2d 
ed., p. 169; Mr. Egan, On Syphilitic Diseases, pp. 293, 294; Erasmus Wilson, On 
Syphilis, p. 36; Geo. McLellan, Principles and Practice of Surgery, pp. 250, 251; 
Dr. Neligan, Dub. Quart. Journal of Medicine, Feb. 1853, p. 119; Dr. Campbell, 
North. Journal of Medicine, 1844, or Cormack's Journal, Sept. 1844, p. 773; Dr. 
John Rose Cormack, Lond. and Ed. Monthly Journal of Medical Science, Sept. 1844, 
p. 773 ; Evanson and Maunsell, On Diseases of Children, Am. ed., p. 350 ; Dr. James 
Stewart, On Diseases of Children, 4th ed., p. 468 ; Dr. John Watson, United States 
Med. and Surg. Journal, vol. 2d, p. 103 ; Dr. H. D. Bulkley, On Syphilis in Infants, 
New-York Journal of Medicine and Surgery, Oct. 1840. We might add to the list, 
but surely it is unnecessary. During our recent visit to Dublin, we were person- 
ally assured by Messrs. Cusack, Adams, Fleming and Wilmot, that they entertain 
no doubts of the correctness of the doctrine here advocated, and we know that 



* Take the orator's own words. It should be recollected that M. Malgaigne is 
the friend of M. Ricord, and that it is from the journal of a friend that they are 
copied. " M. Ricord, possessed of a theatre of observation vast as could be wished, 
began by rejecting the observations of others ; then adopting a certain theory, lie 
disregards those of his pupils made under his own eyes, in his own service* and 
finally, 1 must say it, he takes no heed of his own, when they conflict with his own 
preconceived views." "Vid. V Union Medicate, Aug. 30, 1851. 



5g "VTDAL ON VENEREAL DISEASES. 

among our own countrymen, this view of the subject is inculcated in the lectures 
of Profs. Mott, Mussey, and Parker. Indeed, it is not difficult to find, even in the 
works of the most prominent opponents of this doctrine, viz. Messrs. Ricord and 
Acton, positive proof in its support. As such, we regard Case XV. (God. Eulalie) 
in M. Ricord's Treatise, 4th Am. ed., p. 204, and that of the child infected by the 
cavalry officer, mentioned in his Letters, xiii. p. 105. Again, in his Notes to Hun- 
ter, 2d ed., p. 11 6, he fully admits the transmissibility of the secondary accidents 
in the following language : " There exists a great number of incontestable cases of 
syphilis transmitted from the nursling to the nurse, and vice versa." Further proof 
may be found in the work of Mr. Acton, 2d Am. ed., p. 420. "We refer to the re- 
port of the case of the infected foetus, which contaminated its mother. 

Can a husband, who has suffered from syphilis, but who is apparently sound, 
communicate consecutive accidents to his wife, which accidents, in the latter, shall 
not be preceded by any form of primary sore ? It was the opinion of Mr. Colles 
(op. cit. p. 263), that " a newly-married man, who is himself free from every appear- 
ance of syphilis and every other disease, shall yet infect his wife in such a man- 
ner, that secondary symptoms shall appear in her a few months after marriage, 
and these not be preceded by any primary symptoms, or by any discharge what- 
ever from the genitals." Mr. Carmichael {Clin. Lect, p. 50, 51) states that he has 
met with instances of young married women above suspicion, who were affected 
with constitutional symptoms, yet who, on the minutest inquiry, he could not learn 
ever had any primary venereal affection. But their husbands, though equally 
free from primary, at the time of their marriage, had on them secondary symptoms 
in the form of eruptions or ulceration of the throat. A case of the latter kind 
came under our own care a few years since. The individual married in spite of our 
remonstrances, and about two or three months afterwards, his wife had a similar 
eruption on her lower extremities. We here insert the details of two very interest- 
ing cases, for which we are indebted to Mr. Langston Parker : 

" Case I. — A gentleman contracted a superficial primary sore, which healed 
without leaving a mark or induration behind it. Being apparently in good 
health, he married. Three or four months after his marriage, he perceived on his 
body numerous red, smooth, elevated, scaly blotches ; very shortly his wife broke 
out with an eruption of a similar character, and the hair came off rapidly in both 
patients. In this state, they were sent to me. Neither had any primary disease, 
and the lady had never had the slightest irritation in the genito-urinary organs. 
I examined them both frequently and carefully, and I am positive the wife had 
never suffered from sore, excoriation or discharge. 

" Case II. — A gentleman, who had suffered both from primary and secondary 
syphilis, married, after having been free from all symptoms for twelve months ; 
soon after this he had another eruption and sore throat; his wife became affected 
with the same eruption, excavated ulcers of the tonsils, and was prematurely de- 
livered of a dead child, in the sixth month of her pregnancy. Both patients lost 
their hair and eyebrows. On account of the obstinacy of some of the symptoms, 
in both cases, they were sent to me from a distance to be treated by the moist 
vapour of mercury, under the use of which they both perfectly recovered. In this 
case the lady was more than once carefully examined ; she was free from all evi- 
dence of primary disease, and never had suffered from the least irritation in the 
parts." 

Mr. Porter remarks (Lect. cit, p. 100), that the cases which have come under his 
observation, have led him to the conclusion, " that the semen of a diseased man 
deposited in the vagina of a healthy woman will, by being absorbed, contaminate 
that woman, without the necessary occurrence of a chancre, or any other sore 
secreting matter on either the man or the woman." Prof. Willard Parker has fur- 
nished us with the particulars of three cases in support of this doctrine, and others 
of a similar nature may be found in the paper of Dr. John "Watson, to which we 
have referred. 

Now, if the doctrine here broached be true, and if it also be true, as is main- 
tained by Messrs. Ricord, Cazenave, and Erasmus Wilson, that the syphilitic tem- 
perament or diathesis, when once formed, may last ten, fifteen, and twenty years, 
or, indeed, never be eradicated, when can a man with safety marry, who has had 
constitutional syphilis, but who is free from every external manifestation of the 
disease? Will it do to give him "a clean bill, of health," after a "six months' 
quarantine," as proposed by Mr. Acton (op. cit, p. 416), or after that which has 
lasted from " two to five years," as advised by Mr. Wilson (op. cit, p. 49) ? — 
<€t. G» B. 



A TEEATISE ON YENEEEAL DISEASES. 



PART I. 

PRIMITIVE VENEREAL DISEASE. 

In the announcement of the classification which I have adopted, 
I have already explained what I understand by the terms primitive 
venereal disease. It may arise simply from irritation, or, from a 
specific cause, hence may follow affections non-specific ; or specific, 
virulent. Thus, the lesions discussed in our first division may be 
regarded as simple local inflammations ; certain instances of blen- 
norrhagia are of this class. But, as the syphilitic virus is the most 
common cause, these affections are, generally, neither simple nor 
local; if, for example, chancre should possess this character, it 
would no longer be a chancre, that is, a specific ulceration, but 
simply a suppurating wound. 

After the accidents, which, by all, are regarded as primitive, 
will be found discussed in this division those which by others are 
called consecutive, hence the despair of the nosologists, who pre- 
tend to be strictly logical, and of the syphilographers, who profess 
to be governed by absolute laws ; among these diseases are the 
mucous tubercles. I have assigned them a place between the 
primitive and consecutive accidents, to show that when caused by a 
specific virus the disease is the same, and that the facts which 
relate to it belong to both. A more arbitrary course might sepa- 
rate them; but it should be understood that the arrangement 
here adopted is but provisory and artificial, to assist the compre- 
hension of junior minds. 

Most of the- diseases of this first division are of an acute nature, 
and assume a more or less inflammatory form. Besides the symp- 
toms which may be attributed to the virus, others more direct, 
more immediate, of an inflammatory character, manifest themselves. 
Indeed, if the testicles, the prostate gland, the articulations, the 
eyes, the lymphatic ganglia, become involved through sympathy 
or metastasis, it is under the form of a phlegmasia. The practi- 
tioner is therefore most frequently required to treat an inflamma- 
tion ; and to subdue that which threatens he should promptly direct 
all of his attention, all his means, without reference to its specific 
cause. First of all, the effects must be combated. Antiphlogistics 
must then occupy a prominent place in this division. They seem, 



58 VIDAL OX VENEREAL DISEASES. 

indeed, ultimately to decide everything. The advocates of the 
doctrine of the non-existence of a specific virus have seized upon 
this circumstance, and taking the exception for the rule, the tem- 
porary for the permanent, have proclaimed the constant success of 
simple treatment, such as antiphlogistics, emollients, hygiene, and 
that, consequently, venereal affections do not depend upon a specific 
virus. It is true that simple treatment is sometimes sufficient, since 
nature alone is occasionally adequate to the purpose, especially in 
those cases which are not virulent ; the error lies in the generaliza- 
tions from these results, and particularly in the conclusions drawn 
of the nature of the disease from the means by which it has been 
cured ; they cannot be specific, because they have been cured by 
a non-specific treatment ! The whole science of medicine properly 
interpreted, protests against this error, which would deny the vix 
medicatrix natures, the greatest and most brilliant fact in pathologi- 
cal physiology. 

CHAPTEE I. 

BLENNORRHAGIA. 

From the time of Swediaur, the term blennorrhagia has been 
applied to the inflammation of certain mucous membranes, which 
generally follows impure connection, and the characteristic of which 
consists in a more or less abundant secretion of mucus mixed 
with pus, (muco-pus.) This disease has also been called gonorrhoea, 
which denotes a discharge of semen, and it has been known like- 
wise under the name of chaudepisse, derived from the burning 
sensation which the patient suffers in urinating. These terms, 
like others which I purposely omit, express only a symptom of 
the disease that may be wanting, in which case they would mean 
nothing; thus the seminal flux is an hypothesis; the burning 
sensation may be entirely absent. The word blennorrhagia itself is 
far from being without reproach, for the discharge is not always 
of the same nature ; for example, in the commencement it may be 
mucus, then it may be mucus mixed with pus ; finally, it may 
consist of pus alone. Still worse would it be if there were actually 
a dry blennorrhagia. 

Seat. — The ordinary seat of blennorrhagia in the male is the 
urethra, sometimes it affects the mucous lining of the prepuce and 
the glans penis ; in the female, it occupies the vulva, vagina, ure- 
thra, and the uterus ; in both sexes, the oculo -palpebral mucous 
lining, that of the anus, and lower part of the rectum. The buccal 
blennorrhagia is excessively rare, and it is probable that that of 
the nose is but an imaginary disease. In certain regions, when 
the skin suffers a kind of mucous transformation, blennorrhagic 
discharges may be observed, as, for example, in the genito-crural 
fold, at the internal face of the thighs, and the umbilical region. 
Several of the parts mentioned may be simultaneously affected 
with blennorrhagia : in the male, blennorrhagia of the glans, of 
the prepuce, and of the urethra, may simultaneously exist ; in the 



BLENNORRHAGIA. 59 

female, the entire vulva, the vagina, urethra, the neck and body 
of the uterus, may at the same time be affected. 

Causes. — Blennorrhagia is most frequently observed at that 
period of life during which the functions of the genital organs are 
most exercised, viz. adult age. It has, however, been noticed at a 
very early age, particularly in little girls of a lymphatic tempera- 
ment, which temperament is also favorable to its development in 
the adult. 

Women are more frequently affected than men, and communi- 
cate the disease with greater facility. 

All climates have been observed to be favorable to its develop- 
ment. Among the causes of the disease have been ranked certain 
aliments and exciting drinks; for example, salted food, spices, 
asparagus, truffles, strong liquors, coffee, beer, may really promote 
the action of the direct cause. The excessive use of beer alone 
has been accused of producing a blennorrhagia. Is there any 
foundation for this belief? I am well convinced that this beverage 
will exasperate, and even rekindle an urethritis of long standing 
which has scarcely disappeared, but more than this I have not 
observed. Further, beer exerts but little influence on other than 
urethral blennorrhagias. 

Gout, rheumatism, dartrous, and scrofulous vices have been 
noted among the causes of blennorrhagia. It is certain that the 
existence of a rheumatic, or of a dartrous affection in a patient, may 
modify the progress of the disease : thus, we see rheumatic patients 
affected with blennorrhagia, in whom, during a rheumatic paroxysm, 
the discharge ceases, and yet upon the subsidence of the former, 
the latter reappears ; on the other hand, there are patients who 
notice the appearance of a discharge at each access of their rheu- 
matic attack. Patients afflicted with dartrous affections have been 
observed, whose discharges, like the cutaneous disease, assume a 
chronic character; in such cases it becomes of a serous nature, and 
small in quantity ; the secreting surface is affected with a trouble- 
some itching, and the urethral affection is cured by remedies 
addressed only to the cutaneous disease. Scrofula renders a blen- 
norrhagia chronic, and the discharge in these cases readily assumes 
a gleety character. This is all that can be said of the part which 
the above morbid conditions play in producing or modifying the 
characters of a blennorrhagia ; beyond this all is hypothesis.* 

* Mr. Henry James Johnson, On the Genito- Urinary Organs, part i. p. 37, after 
alluding to the influence of gout or scrofula in predisposing to blennorrhagia, 
observes: "but, I am mistaken if those peculiar states of system do not, occasion- 
ally, produce the complaint without the interposition of any obvious exciting 
cause." He then gives the details of two cases which support the above view of 
the subject. As to the influence of gout in producing a blennorrhagie discharge, 
we have no doubts whatever. About four years since we treated a patient some 
seventy years of age, who was the victim of gout, and during one of his attacks he was 
seized with a most copious urethral discharge. We know, positively, that this dis- 
charge depended upon no other cause than the gout. Dr. John Watson, of this 
city, informs me that two cases of the kind have come under his observation. 

Numerous and serious medico-legal questions may arise in connection with the 
subject of urethral and vaginal discharges, both in children and the adult. The 
reader may find, both in the works of Beck and Taylor, on Medical Jurisprudence, 



(50 VIDAL ON VENEREAL DISEASES. 

The direct causes are either physical, chemical, or pathological : 
thus, a calculus passing through the urethra, the introduction of a 
sound, an ammoniacal injection (Swediaur), all of these agents 
may give rise to a muco-purulent secretion. Coitus too often re- 
peated, or performed with organs of disproportionate size, mastur- 
bation, menstrual blood, the ichorous discharge from a cancer, the 
lochia, and especially the fluor albus, are so many causes which 
have been accused of producing blennorrhagia, and which, of 
course, are particularly furnished by the female. 

Yirulent pus, that which is the medium of the syphilitic virus, 
is, in my opinion, the most frequent and powerful cause of blen- 
norrhagia. Those who deny that specific pus can give rise to a 
virulent blennorrhagia, have nevertheless supposed that it may act 
upon the mucous membranes like any simple irritant ; those who 
are unwilling to admit the power of the virus to produce a primi- 
tive syphilitic blennorrhagia, have acknowledged that it may give 
rise to the same disease, but of the consecutive form. Syphilitic 
virus is therefore entitled to a prominent place in the etiology of 
blennorrhagia, a fact which should be borne in mind when we 
come to the treatment of the disease. 

A general view of the causes mentioned shows that they act di- 
rectly upon the mucous surfaces, or indirectly after they have 
passed through the system. Thus, the syphilitic virus should have 
this double action, and the rheumatic diathesis can act but indi- 
rectly. It is evident that blennorrhagia, from an indirect cause, 
cannot be of a simple nature, and that among the cases which pro- 
ceed from a direct cause, there are few whose action is limited to 
the production of an inflammation. Such is the fact only where 
the disease has been caused by foreign bodies, excessive indulgence 
in coitus, masturbation, menstrual secretion, and the fluor albus 
which has accidentally become a little acrid. 

Whatever may be the nature of the blennorrhagia, certain pecu- 
liarities of the discharge, of its organic vital conditions, affect its con- 
tagious properties. Thus, the predominance of pus in the secretion is 
favorable to contagion ; in proportion as mucus predominates, that 
is, as the disease is less acute, the less are the chances of contagion. 
But there can be no doubt that very trifling discharges, clrojjs, 

several interesting and instructive cases recorded, from -which he may learn the 
great difficulty which occasionally attends the diagnosis between the virulent and 
non-virulent discharges. We can only refer to some of the principal sources of 
information upon these questions. Rayer, On Diseases of the Skin, Translated by 
Dr. Willis, London, 1835, p. 165. Also Memoir by the same author, "sur les inflam. 
non-virul, memb. mug. des org. de la generat. des Fnfans," Paris, 1821. Capuron, 
Med. Leg. des Accouchemens, p. 41. Mr. Kesteven, Lond. Med. Gaz., vol. xlvii. p. 372. 
British Amer. Journal, May 1848, p. 19. Dr. John Rose Cormack; Observations on 
Gonorrhoea and Syphilis, with reference to Forensic Medicine, dec, in Lond. and Edin- 
burgh Monthly Journal, Sept. 1844, p. 753. Sir Astley Cooper, Lectures on Surgery. 
Benjamin Bell, On Venereal, vol. i. p. 416. Dr. Underwood, Diseases of Children. 
Mr. Moses, Lond. Lancet, Dec. 1835, p. 443. Frederick C. Skey, Lectures on Vene- 
real Disease, Lond. Med. Gazette, vol. xxiv. pp. 439, 440. Wm. Lawrence, On a Pecu- 
liar Affection of the Genitals in Female Children, Lond. Med. Gazette, Aug. 21, 1830, 
p. 828. Mr. Egan, On Syphilitic Diseases, p. 130. G-. C. B. 



BLENNORRHAGIA. 61 

"which, are regarded as of no consequence, may communicate very- 
severe and sometimes very virulent attacks. 

There are individuals so constituted that they may with impu- 
nity expose themselves to the risk of contagion. There exists be- 
tween the parts brought into contact during coitus a certain sym- 
pathy of action, an adaptation of form and volume which singu- 
larly favors or prevents the development of blennorrhagia : thus, a 
man shall live for many years with a woman who has a discharge 
from the vagina, and yet shall himself escape ; habit has created a 
kind of harmony in the vitality, the form, and the volume of the 
organs which produces this immunity ; but let the habits of the 
woman become changed, let her have a new lover, and the latter 
shall perhaps contract a blennorrhagia at every menstrual period. 
Facts of this nature have been observed by every practitioner who 
is consulted by patients affected with venereal disease. Fallopius, 
a writer of the XYIth century, remarked that certain infected 
women communicated nothing to their husbands with whom they 
had no sexual pleasure, but gave disease to their lovers who grati- 
fied their desires. 

Certain conditions of vitality may then promote contagion, and 
it is an established fact that blennorrhagia is almost always com- 
municated by coitus. But blennorrhagic pus, which is simply de- 
posited upon a mucous surface, may produce the same effect ; the 
experiments of the students mentioned by Benjamin Bell prove 
this fact. It has been asserted that pus which has been swallowed 
and absorbed in the stomach, so directs itself to the genital organs 
as to determine a blennorrhagia. The proof of this is still wanting. 

Nature. — In discussing the question of the nature of the syphi- 
litic virus, I have anticipated the difficulties which would arise 
when we come to study the etiology of blennorrhagic discharges. 
I have stated that Hunter believed that these discharges recognized 
the same cause as chancre, and that this cause was the syphilitic 
virus, the effects of which differ according to the surfaces to which 
it is applied. But, as the vagina, according to Hunter, is a secret- 
ing surface, and as upon the mucous lining of this canal true chan- 
cres have been observed, the theory of the English surgeon is thus 
strongly compromised. 

I have noticed the opinion of Benjamin Bell, who admits two 
morbid elements, the one blennorrhagic, the other chancrous. 
Finally, I have mentioned the opinion which views blennorhagia 
as dependent upon an inflammation caused simply by an irritation, 
xhe effects of which are local, and never resemble those produced 
by a morbid poison. When the latter effects have been observed, 
then it was owing to the carelessness of the observer, or indeed he 
was ignorant of the proper method of investigation, or he knew 
not how to manage ; he could not hav.e discovered a chancre hidden 
under a narrow prepuce, in a fold of the vagina, or upon the neck 
of the uterus, or in the canal of the urethra. The observer could 
not, or knew not how to detect anything but the discharge, and 
taking this symptom for the disease itself, he has placed on his 
list, under the head of diagnosis, blennorrhagia, when it should have 



52 TO) AX OX VENEREAL DISEASES. 

been chancre. It must at once be admitted that errors of this 
kind have been largely committed, especially at a time when the 
hint had not been given, and before they possessed the means of 
investigation which we now enjoy. But Hernandez had already 
inaugurated the chancre larve; Hunter dwelt at length upon those 
cases in which a chancre may escape detection, and our contempo- 
raries, at the head of whom must be placed M. Eicord, for twenty 
years have spoken of these errors and their causes, and have taught 
the method of avoiding them. The speculum, in fine, has rendered 
the argument drawn from the imperfection in observation, much 
less forcible than it was before. With regard to ignorance and 
want of skill, these are daily disappearing, and there are practi- 
tioners who from their position and reputation as honest and saga- 
cious observers, put to naught this argument as well as another 
too often employed in desperate cases. These practitioners believe 
that there really exist syphilitic discharges which have no connec- 
tion with chancre, which has always been absent at every period 
of the blennorrhagia ; further still, the syphilitic nature of these 
discharges has been shown by the appearance of secondary acci- 
dents, by the general manifestations of poisoning. No objection 
can be seriously urged against similar facts observed in the female 
where the urethra remains sound, without any discharge ; for the 
Vulva, vagina, the neck of the uterus, the anus may here be direct- 
ly explored, but when it concerns a urethral blennorrhagia in the 
male, the chancre larve renews all its claims. This has been sup- 
posed even when the pus from the urethra could not be inoculated. 
Thus then, in order to combat a pretended supposition, that is to 
say, the non-existence of chancre in virulent blennorrhagia, a sup- 
position has been employed, an established principle has been vio- 
lated, a chancre in the urethra has been supposed when syphilitic 
accidents have supervened, and all this because it is pretended, that 
chancre alone can produce these accidents. Now this is the point 
in question. I myself, do not admit the existence of chancre be- 
yond the navicular fossa, I am aware of what has been written 
concerning the deep-seated urethral chancre ; some pathological 
specimens even of which have appeared satisfactory to those who 
exhibited them. But I must confess, after a very careful exami- 
nation of that regarded the most important in proving the exist- 
ence of a profound urethral chancre, I am convinced that it was a 
case not of syphihtic, but of tubercular ulceration, which existed 
at the same time in the form of cavities in the prostate gland, in 
the testicle and in other organs of the same patient. I observe 
that some excellent surgeons partake of this same doubt,* M. 

* In his Communication to the Academy of Medicine, Oct. 12, 1852, {Be la Sy- 
philization, &c, p. 367,) M. Velpeau thus remarks : " The specimens presented by 
M. Eicord as examples of chancre, are far from being incontestable. In one of 
them, I recognize that of a tubercular young man, having large cavities in the 
prostatic portion of the urethra, and I see no indication that chancre had existed 
there ; the other is that of an old man, almost equally obscure. I saw these spe- 
cimens when first exhibited to the Academy, but they were far from satisfying me 
of the existence of chancre." The report of these cases in the Treatise of M. Ricord 
(4th Am. ed. pp. 126, 127), is exceedingly meagre and unsatisfactory; compared 






BLENNORRHAGIA. 63 

Baumes cannot understand how the pns of a chancre can traverse 
the great extent of the urethra without leaving any trace on its 
passage ; in fine, without producing ulceration but at one point 
of this canal. M. Chomel remarks, with his accustomed modera- 
tion : " It is only an exceptional case where the presence of a 
chancre in the urethra has been demonstrated or rather presumed"* 

But admit, for a moment, the existence of chancre deep in the 
urethra, provided that it is rare, and exceptional, and that we have 
the candor to acknowledge. Now compare the frequency of ure- 
thral chancres with the number of consecutive syphilitic accidents 
which have been seen to follow urethral discharges, and the enor- 
mous number of the latter compared with the former cases, will 
at once be apparent. Physicians who devote special attention to 
the diseases of the skin, as, for example, MM. Cazenave, Martins, 
Legendre, will tell you that blennorrhagia produces as many cu- 
taneous affections as chancre. Now, deduct some cases of blen- 
norrhagia which you may carry to the column of urethral chancres 
(if you admit their existence), there will remain a considerable 
number of eruptions which can be attributed only to blennor- 
rhagia. This truth has been proclaimed before the whole Academy 
of Medicine, particularly by men who have long been observers, 
and who have been committed to no particular theory in syphil- 
ography, such as MM. Moreau, J. Cloquet, Velpeau, P. Dubois, &c. 

Now, admit still further, that every specific syphilitic discharge 
is but a symptom of chancre. There will still, however, always 
remain a form of inflammation of the mucous membranes, a sero- 
purulent discharge, — in fine, a blennorrhagia, which by its progress, 
its duration, its accidents, its complications, can never be referred 
to an inflammation like that produced by simple irritants, by for- 
eign substances, by ammoniacal injections, or that which Swediaur 
produced upon himself. These simple inflammations are not 
communicated with the same characters, from one individual to 
another ; they are not followed by the accidents of metastasis, 
such as blennorrhagic ophthalmia, or blennorrhagic arthritis ; 
they do not continue a year as did the blennorrhagia which that 
student gave himself, by applying between the prepuce and the 
glans, pledgets dipped in gonorrheal matter, f All these effects, 

with that in his Notes to Hunter (pp. 799, 803), it will be found to differ in several 
particulars, and in our humble opinion, the chapter (p. 147) on ulceration of the 
bladder in the excellent Treatise on the Urinary Organs by our countryman, Prof. 
Gross, or that on Scrofulous Prostate in the work of Mr. John Adams on the Anat- 
omy and Diseases of the Prostate gland, pp. 117, 125, afford a far more correct solu- 
tion of the true nature of these cases. The ulceration in these cases was of very 
great extent, involving the urethra, bladder and prostate; yet when we find M. 
Ricord, in 1851, (Letters, viii. pp. 59, 60,) inculcating the doctrine, that the urethral 
chancre is never very extensive, and that when we find an abundant discharge (as 
existed in these cases), we may conclude that it is something more than the pro- 
ducts of a chancre, we are astonished that he does not even allude to those very 
remarkable exceptions. At any rate, the fact that his diagnosis in those oases is 
questioned by such men as MM. Velpeau, Vidal, and Prof. Gross, (as we learn from 
a recent letter from the latter gentleman,) is sufficient to render them far from be- 
ing, as is asserted by M. Ricord, "incontestable." — Gr. C. B. 

* Abeille Medicate, Jan. 1851. Lecon clinique de M. Chomel. 

| B. Bell, on Venereal, t. ii. p. 492. 



64; VIDAL 03" VENEREAL DISEASES. 

which, are not denied by my opponents, proceed from a single 
cause, which does not simply irritate the mucous membrane, but 
which penetrates the system. Now this cause we may call a vice, 
or virus ; we may say, that it is not syphilitic, that it is gonorrheal. 
We come then to the conclusion of Benjamin Bell, and admit a 
double virus, or more properly speaking, we apply two names to 
the same virus, which really requires much less expense of the 
imagination, much less research, much less time, since it is already 
made.* M. Baumes also admits a double virus, that of chancre, 
and that of blennorrhagia ; the action of the latter, in his opinion, 
is not confined to that of irritation, it is absorbed, and then it does 
terminate in the production of primitive accidents, such as bubo, 
ophthalmia, arthritis, but it gives rise to such symptoms as are de- 
scribed in the following remarkable passage : "I can affirm," said 
Mr. Baumes, " that during the past three years alone, I have seen 
at the hospice de VAntiquaille, exclusive of my practice in the city, 
-Qye cases of simple blennorrhagia, where I am certain that there 
was no chancre in the urethra, which cases were followed after 
some time, by constitutional symptoms, such as well-marked 
rounded idcers on the tonsils ; mucous tubercles at the commissures of 
the lips, about the anus, and on the scrotum; syphilitic ecthyma; fur- 
fitraceous, squamous, and papular eruptions, &c, &c. In two of these 
cases, on the seventh or eighth day from the commencement of the 
blennorrhagia, I inoculated with muco-pus, by three punctures on 
each thigh, without any result."f M. Baumes then admits, that 

* For farther proof of the existence of a blennorrhagic virus, which virus pro- 
duces ulceration, buboes, arthritis, ophthalmia, sore throat and papular eruptions 
— the reader may consult Mr. Carmichael (Clin. Lectures, pp. 2041) ; Mr. South (Ed. 
of Chelius, vol. i. Am. ed. p. 188); Erasmus Wilson (on Syphilis, p. 53); Mr. Bacot 
(Treatise, j>. 126;) Langston Parker (Mod. Treat of Syph. Diseases, pp. 32, 43); Mr. 
Egan (on Syph. Diseases, pp. 17, 18, 21, 59, 60); Mr. Wallace (on Venereal, p. 264); 
Henry I. Johnson (on Gonorrhoea, &c, p. 23); M. Ricord (Notes to Hunter, pp. 59, 
60; also Treatise, Am. ed. pp. 10, 284), in both of which he insists upon the fre- 
quent connection between blennorrhagia and ulceration. Even Mr. Acton, (2d 
Am. ed. of Treatise, p. 222,) states that "we are compelled to admit that in gonor- 
rhea the system is so modified as to become affected by rheumatism ;" again, at 
page 36, he says, that we should not be deterred from attempting to cure gonor- 
rhea rapidly by the fear of driving the disease into the system, for, " it will rush 
in fast enough." And yet, in view of the above fact, Messrs. Ricord, Acton and 
Bransby Cooper persist in proclaiming that blennorrhagia is a non-virulent, non- 
specific disease! But, asks the former, (Lett. v. p. 37), is it not true that in the 
immense majorityof cases, blennorrhagia is not followed by syphilitic infection? 
Very true, and in this respect, it resembles the superficial primary chancre. 
"There are chancres," says the same high authority, "and perhaps these constitute 
the greater number, which do not infect the system." (Lett, xxviii. p. 207). The 
testimony of Mr. Acton is to the same effect ; at p. 264 of his Treatise, (Am. ed.) he 
observes, " that in simple, uncomplicated chancres, secondary symptoms occur in 
such feeble proportions that they should not enter into our calculations." Again, 
blennorrhagic matter, applied to the lining membrane of the eye-lid, contrary to 
the assertion of M. Ricord (Treatise, Am. ed. p. 67), does sometimes produce chan- 
cres (ulceration) of the palpebral lining, which is followed by peri-auricular bil- 
boes. For proof, as furnished by Dr. Mairion of the Military Hospital at Louvain, 
Mr. Wilde and Dr. Egan of Dublin, see the Treatise of the latter gentleman, pp. 
114, 115. These facts viewed in connection with those which we shall presently 
adduce in favor of its inoculability, and its mode of propagation, we believe suffi- 
cient to entitle blennorrhagia to be regarded as a specific disease, independent of 
the existence of chancre larve. — G. C. B. 

t T. i. p. 233. 



BLENNORRHAGIA. 65 

urethral discharges may be produced : 1. By a chancre ; 2. By a 
virus, which is not chancrous, but which gives rise to the accidents* 
already mentioned ; 3. By an irritation or inflammation which 
produces but sympathetic effects. M. Bicord is of the opinion that 
M. Baumes has arrived at these conclusions from conciliatory mo- 
tives. For my own part, I believe that M. Baumes has, by a long 
and directly opposite method to M. Bicord, formed the opinion, 
that there are urethral discharges without any chancre, which are 
virulent, and capable of giving rise to consecutive syphilitic acci- 
dents ; only, these accidents may be less frequent, less profound. 
But there are chancres which frequenly do not produce consecu- 
tive accidents, and the latter are not always profound. Experi- 
ment, besides, here steps in with unanswerable arguments; for 
Hunter proved that the pus of chancre and that of blennorrhagia 
might produce both chancre and blennorrhagia.* When I reach 

* Mr. Carmichael claims Cases xiv. p. 108 ; ix. p. 104; xx. p. 113, and xv. p. 109 ; 
in the Treatise on Inoculation (4th Am. ed.) by M. Ricord, as proof that the matter 
of blennorrhagia like chancre is inoculable. To the above, we would add Case lxi. 
p. 185. In this case the matter was taken from a bubo following blennorrhagia, and 
the pustules produced are called false pustules. If with the report of this case, the 
reader will peruse M. Ricord's account of the characteristic pustule, (Lett, xviii. p. 
142), and that of the false pustule at page 146 of the same Letter, we think that he 
will hesitate before he accepts the pointed pustules with slight induration, pro- 
duced by this inoculation, for pseudo-pustules. The latter, we are distinctly told, 
(Lett, cit.) never lasts longer than from five to six days, yet the pustules in this case 
lasted thirteen days. That they healed' without treatment is surely no evidence 
that they were not syphilitic, for this is a test on which, we believe, neither M. 
Ricord nor any modern authority relies. In his Treatise, (p. 255,) he states that 
"the primary specific ulcer may often heal without treatment," and Mr. Acton 
(op. cit. p. 255) assures us "that some syphilitic sores heal in twenty hours." In- 
deed, this spontaneous healing of chancre was known even to Abernethy, (pp. 48, 9.) 
In the report of the above case, it is mentioned that the pustules did not assume 
the appearance of specific ulcers. Now, what is the appearance of a specific ulcer. 
In another part of this work, we have already shown that an absolute diagnosis 
cannot be formed from the physical characters of an ulcer, a fact admitted even by 
M. Ricord himself. Though in his Letters, (xviii. p 138,) he informs us, that in true 
inoculation, the dermis is completely bored, as if with a punch, in the same Letter, 
(p. 141,) he states, that the primary ulcer does not always destroy the entire thick- 
ness of the skin or mucous membrane. Indeed, this distinguished syphilographer 
has at length been compelled to admit that, after all, there is no characteristic pus- 
tule. In his inoculations on M. Laval — that martyr to syphilization — M. Ricord in- 
sisted that the little ecthymatous pustules which he produced, and which speedily 
disappeared without ulceration or suppuration, were genuine chancres, only, of a 
particular form (seulement avec une forme pariiculiere). For proof of this assertion, 
seethe Communication of M. Depaul to the Academy of Medicine, July 2*7, 1852, 
(Be la Syphilization, &c. p. 54,) and that of M. Ricord himself, (op. cit. p. 67.) But, 
is it reasonable to suppose that a virus, which, when applied as in the ordinary 
modes of propagation, produces effects so diversified, should on artificial inocula- 
tion produce the same invariable results ? The numerous experiments of Mr. 
Egan, of^ Dublin, and M. Sperino, of Turin, if further proof be wanting, conclusive- 
ly settle this question. Mr. Egan (op. cit. p. 21) observes : " in some of the cases 
to which I allude, the only effect produced (on inocidation), was slight inflamma- 
tion, which in the course of a few days subsided ; in others, the inflammation ran 
to a higher pitch, and terminated in an unhealthy phlegmonous abscess; while, in 
a third, no visible effect was at all discernible. These remarks apply more parti- 
cularly to the first class of primary ulcer" (the superficial). It will be remem- 
bered that the matter used in these experiments, was taken from ulcers which were 
followed by constitutional infection. On this subject, the reader may also consult 
the Treatise by M. Sperino, " on Syphilization," p. 94. At p. 501, he informs us that 
the pus of the so-called false pustules has been proved by his experiments to be 
improbable. There is at present (August 9, 1853), in the New York Hospital, a 

5 



6$ VIDAL ON VENEREAL DISEASES. 

the subject of balanitis, I will prove that trie pus secreted bj trie 
•glans and trie prepuce, which is not ulcerated nor even excoriated, 
may produce chancres. Now, in this case, even the pretext of the 
chancre larve cannot be invoked, for it is one of external blennor- 
rhagia ; the whole surface furnishing the humor may be directly 
explored. Thus the existence of virulent blennorrhagia is proved 
by the writings of those opposed to the doctrine, and this from 
the simple circumstance, that it is a fact. 

Incubation. — Incubation, like that of chancre, has here been 
admitted and denied. The period of incubation is generally 
exaggerated by patients : thus, it is not uncommon to hear them 
speak of eight, and fifteen days elapsing between the suspected 
coitus and the first appearance of their blennorrhagia ; they have 
even gone as high as fifty days. The majority of patients, having 
suffered nothing at first, and the discharge being but trifling and 
colorless, they mistake the starting point of their disease. We 
should, therefore, in general, mistrust the computation of most 
patients. But there are those who begin immediately after their 
suspected coitus, to watch the most trifling phenomena which ap- 
pears on the genital organs ; and among these observers are found 
not only men of the world capable of noting these phenomena, but 
even experienced physicians. Now, these persons have noticed a 
real incubation ; that is, twenty -four hours and three days have 
passed without anything being discovered, absolutely nothing; 
after this interval, a sensation of pricking, of itching, followed by 
a more copious secretion of mucous, which afterwards becomes 
troublesome, indicates that they have contracted the disease. This 
has been observed not only in urethral blennorrhagias, but also in 
those of the prepuce and glans, which are directly open to our 
observation. It must be admitted, however, that certain cases of 
blennorrhagia, especially those which follow sexual intemperance, 
are said to create, even on the first day, a modification in the sen- 
sibility of the parts ; and that on the second, the discharge appears. 
Most generally the truly inflammatory phenomena are not estab- 

patient, named Hugo Kiel. He is 18 years of age. On the 6th of June, eight days 
after exposure, he first felt a burning sensation at the meatus. This was followed 
in a day or two by a discharge, which soon became profuse. He is positive that 
he has never suffered pain except when urinating. A bubo appeared on the right 
side two days after the commencement of the discharge. In the course of a week, 
this was opened, and the matter successfully inoculated three weeks from the first 
attack. At present, we can detect no roughness within the urethra, though we 
have examined most carefully with a bougie, nor can we detect any induration 
along the track of the canal. The patient assures us that he has never been able 
to detect the slightest hardness, or any unnatural feeling. Is this a chancre larve ? 
As such it is regarded by the talented surgeon (Dr. Van Buren) who performed 
the inoculation, and who has charge of the patient. The only proof, however, of 
the existence of a concealed chancre in this case, is the fact, that inoculation pro- 
duced positive results. Believing with M. Ricord, that chancre alone is inoculable, 
the successful inoculation is to him proof positive of the existence of a chancre 
larve. The fact being now incontestably established, that secondary accidents, 
and blennorrhagia, may produce positive results on inoculation, (for further proof 
of the latter, see Thesis of M. Barthole, 1845,) with all due respect to the opinion 
of the above-named surgeon, in the instance of Hugh Kiel, we can, after the most 
diligent search, discover nothing more than an ordinary case of blennorrhagia.— 
G. C. B. 



BLEKCTORRHAGIA. 67 

lished until the fifth day, at which period pus predominates over 
the mucus. 

Symptoms. — I have already stated that in the commencement 
there is a modification of sensibility, which is most frequently in- 
creased as are the functions of the organ, especially its normal se- 
cretion. In the second stage, there is real pain and dryness of the 
mucous membrane, which is but of short duration, and soon gives 
place to a morbid secretion. This secretion is a mixture of pus 
and mucus, muco-pus. At first of a white color, it assumes a yel- 
low shade, and after awhile a deeper color. As the discharge be- 
comes more abundant, the muco-pus is turned to a greenish color. 
This is owing to the presence of some blood-globules which by 
their increased numbers give to the discharge a reddish aspect. 
These shades are particularly observed in cases where the discharge 
is of a sanious sero-sanguineous character. But in general the color 
depends upon the mixture of pus with the mucus. In the acute 
stage of the disease the matter discharged has an odor which gene- 
rally resembles that of decayed codfish ; sometimes, even in the 
urethral discharges of the male, it has a faint sickish smell like 
that of leucorrhcea. It is very true that the odor may be rendered 
remarkably strong by a neglect of cleanliness. But this alone 
does not give rise to it, nor decide its character. Thus, when we 
find a subject with a large number of mucous pustules on the geni- 
tal organs, we perceive an infectious odor, which, however, is not 
the same as that exhaled by a patient affected with blennorrhagia, 
even when both subjects are guilty of the same want of cleanli- 
ness. I do not agree with those who so much despise the odor in 
trying to distinguish the different kinds of blennorrhagia. I have 
observed urethral discharges in the male of a sour and nauseous 
smell like that of the fluor albus of the woman with whom he had 
had connection. 

Progress. — Sometimes at the commencement of an attack of 
blennorrhagia, we find general disturbance of the system, such as 
chills and febrile reaction. It often begins without any premoni- 
tory symptoms, and proceeds to a chronic state, or what is less fre- 
quent, to a rapid and perfect cure. This termination is often ob- 
served in those forms of the disease which are, so to speak, exter- 
nal, like that of the prepuce and the vulva. But, when the disease 
is more deeply seated, when irritating humors are brought into 
contact with the inflamed surfaces, as happens to the urethra so 
often traversed by the urine, then there is less hope for a speedy 
termination. Sometimes, especially in those who have been often 
affected, it puts on a chronic form from the beginning, and then 
the tenacity of the discharge is in direct proportion to the number 
of attacks which the patient has suffered. 

The decline of a blennorrhagia is particularly marked by the 
predominance of mucus over the pus, by the separation of these 
two elements of the blennorrhagic discharge. Some globules of 
pus, so to speak, are found wandering in the mucus, or the stain 
upon the linen is of a grayish Color with a point at the centre of a 
deeper tinge : finally the linen is no longer marked. The duration 



(58 YIDAL 0$ VENEREAL DISEASES. 

oi blennorrhagia, where it is somewhat severe, varies from four to 
six weeks, from six months to a year. There are few exceptional 
cases where the discharge is permanent, but in such cases there is 
reason to suspect the existence of a stricture, an absence of hygiene, 
an imprudence in the diet, which incessantly renews or rekindles 
the discharge. M. Cazenave believes that when these relapses 
occur, it is owing to the existence in the first place of a virulent 
blennorrhagia, which has left the urethra susceptible to the least 
irritation, and there it is that non-specific causes produce discharges 
with the greatest facility. 

Diagnosis. — The diagnosis of blennorrhagia brings us to the con- 
sideration of the chancre larve. In the female, by the proper ap- 
plication of the speculum, we may discover ulcerations on the neck 
of the uterus, the walls of the vagina, or learn whether the disease 
be simply one of blennorrhagic inflammation. In the male, the 
difficulties are great in the way of diagnosing a chancre deep in 
the urethra.* Some syphilographers who admit the existence of 
this chancre, are satisfied when with a catheter they detect a 
roughness at the seat of ulceration ; but a thickening, or a fold of 
the mucous membrane may give rise to the same sensation. Then 
comes inoculation : now nothing can be more unfaithful than this 
latter means, since those who admit the urethral chancre maintain 
that it is inoculable only at a certain stage of the disease, and be- 
cause the matter withdrawn by the lancet may be furnished by the 
portion of the canal which is in front of the chancre, where the 
inflammation is supposed to be of a simple character. In this 
manner may be explained the fact, that M. Bigot, in the service 
of M. Puche, inoculated with urethral pus sixty-eight times with- 
out success. These difficulties besides have been admitted by those 
with whom urethral chancre plays so important a part in the pro- 
duction of virulent discharges. As I do not believe in the deep- 
seated chancre, and admit only that of the meatus and the fossa 
navicularis, my mind is less prepossessed with the difficulties of 
diagnosis. 

It is difficult to distinguish simple blennorrhagia, that which is 
but a catarrhal inflammation from virulent blennorrhagia. How- 
ever, if we can establish a true incubation, if the discharge has a 
tendency to become chronic, we have reason to suspect a specific 
discharge ; if, on the contrary, it has followed excessive sexual in- 
dulgence, if its progress be rapid and the interval brief between 
the coitus and the attack, if the termination be sudden and rapid, 

* The best speculum for the male urethra with which we are acquainted, is that, 
devised by Mr. Avery of the Charing Cross Hospital, London. It consists of a coni- 
cal metallic tube, into the outer funnel-shaped extremity of which the light is 
thrown from a reflector fastened to the forehead of the surgeon, through which is 
an orifice sufficiently large to admit the light to reach the eye of the examiner. 
Through the politeness of this skilful surgeon, we have had opportunities of ex- 
ploring the seat of strictures, and could not but admire the distinctness with which 
the interior of the urethral canal was brought into view. Still, as we have already 
shown on the authority of M. Ricord, the physical characters, even of the external 
primary ulcer are so diversified, that from them alone we cannot pronounce upon 
its nature, and though we may succeed in exposing an urethral ulceration our di- 
agnosis is not yet fully established. — Gr. C. B. 



BLENNORRHAGIA. 69 

we have strong grounds for deciding in favor of a simple blennor- 
rhagia. At a later period, if accidents supervene, the diagnosis is 
then completely established. 

Prognosis. — The prognosis depends upon the seat of the blen- 
norrhagia, the age of the patient, the temperament, the intensity, 
and the duration of the disease. In urethral blennorrhagias we 
have to dread the occurrence of strictures, affections of the bladder, 
of the kidneys, and in the male, the prostate gland. In advanced 
age the latter accidents are most frequent : at an earlier period of 
life orchitis is offcener observed. The more protracted the disease, 
the more have we to fear the production of strictures. Previous 
attacks are favorable to new contagions, and renders the treatment 
less successful ; but the patient suffers less in proportion to the fre- 
quency with which he has been affected. The nature of blennor- 
rhagia modifies the prognosis: there is a vast difference between 
the gravity of that which is simply inflammatory, and that which 
is virulent. 

Pathological Anatomy. — The lesions of tissue observed in cases 
of blennorrhagia must vary according to the seat of the disease ; 
these will be particularly examined when we treat of urethral 
blennorrhagia in the male. I may observe, in a general manner, 
that the mucous membranes have been found of a deep red color, 
and thickened by plastic infiltrations of the subjacent cellular tissue, 
and by abscesses. Ulcerations have been observed, even simple 
ulcerations, the reparation of which by modular tissue may give 
rise to stricture, if a canal be the seat of the disease. The same re- 
sult may be produced by the reparation of the loss of substance 
caused by the passage of the pus through the urethra which was 
formed around this canaL 

Accidents. — These depend upon the seat of the disease ; they will 
be made known when we come to treat of particular forms of blen- 
norrhagia, especially that of the male urethra, described in the 
next chapter. 

Treatment. — This, in the first place, should be prophylactic. I 
do not believe that we are ever under the necessity of practising 
coitus under circumstances where we have reason to apprehend 
contagion, and still less when we have reason to suspect that we 
are sufficiently diseased to communicate a blennorhagia. Mediate 
coitus has been recommended where there is reason to fear conta- 
gion ; it certainly is a means of prevention, but not an infallible 
one * The coitus attended with the least risk is that which is 
quickly performed, is not often repeated, and which is complete, 
as the ejaculation may carry away the contagious matter which 
might have entered the urethra. For the same reason it is of ad- 
vantage to urinate immediately after the act ; the latter, however, 
should not lead one to dispense with thorough ablutions with 
some mild astringent lotion. Those who have suffered, if their 

* The intermediate consists of a small sac made from esccum of a sheep. This 
discovery, which by its utility deserves the gratitude of the public, gave to the 
unfortunate Englishman who left to it his name, such an unenviable notoriety, 
that he was obliged to assume another. 



70 YIDAL OX VENEREAL DISEASES. 

memory serve them, will admit that a surprise, carelessness, too 
much confidence in the person with whom they had intercourse, 
prolonged coitus, a false shame in asking for the means of ablution, 
were among the circumstances which led to their misfortune. 

As in the case of chancre, some advise in this disease, the abor- 
tive method of treatment. This can be proper only at the com- 
mencement of the disease, before inflammation appears ; in fine, at 
the very outset of the malady. Now, the interval between the 
suspected coitus and the first appearance of the inflammation is 
not always the same, for sometimes it occurs in twenty -four hours 
from the application of the cause, whilst in other instances seven 
days have passed before it becomes well marked : then, the means 
could no longer be abortive, but on the contrary would tend to 
aggravate the inflammation, to prolong its duration, and to pro- 
duce serious consequences. I shall never forget the case of a man 
whose absent wife was expected in a very short time after he dis- 
covered that he had contracted a blennorrhagia. He applied to 
me for a sure method of at once arresting the disease. As I could 
not promise this, he consulted another practictioner who advised 
a caustic injection into the urethra, which produced a most severe 
and painful inflammation of the canal and of the bladder. I was 
requested to treat this patient, who was confined in his bed for a 
month, during which time the most energetic antiphlogistic treat- 
ment was required.* 

Could we be consulted at the very moment of contagion, when 
the virus is producing its first effects, and were there a characteris- 
tic symptom of this period in blennorrhagia, we should act at least 
rationally in trying to destroy the cause at the part affected, as 
well as its effect, which must then be local and very limited. But 
this is very seldom possible. Besides, it is necessary that the point 

* Mr. Langston Parker, in a letter to the writer, dated May 31st, 1853, thus ex- 
presses his opinion of the abortive treatment in blennorrhagia : 

" When a patient seeks advice before the inflammatory symptoms are set in, an 
attempt may be made to extinguish the disease by what has been called abortive 
treatment, but if there be decided marks of inflammation and any pain in micturi- 
tion, and if the disease have existed more than twenty-four hours, this treatment 
will be attended, to say the least, with risk, if not with injury, and under the most 
favorable circumstances it will not always succeed." 

In addition to the above extract from the manuscript copy of the third edition 
of his valuable work on the " Modern Treatment of Syphilitic Diseases," now in 
preparation, which he has had the kindness to furnish me, he observes, " but under- 
stand, I never employ the nitrate of silver in stronger solutions than from 2 to 5 
grains in 8 ounces of water. I have seen death result in one case from a stronger solu- 
ion. For the details of another fatal case, from the nitrate of silver, see the work al- 
ready quoted of Mr. H. J. Johnson, p. 59. We think that it may be safely asserted that 
the majority of the Londpn and Dublin surgeons are opposed to the abortive treat- 
ment, except under the circumstances mentioned by our author, with whom, as will 
be observed, M. Parker so strongly coincides, During our recent visit to Dublin, 
Mr. Adams, of the Richmond Hospital, assured us that it was not a favorite method 
in that city, and that in Dublin it is called the "abominable" treatment! We 
have # tried the chloride of zinc, as proposed by Mr. Lloyd, of St. Bartholomew's 
Hospital, London (London Lancet, Dec. 1850), and though at first much pleased 
with its effect, have been taught by further experience, that in some of our 
posed cures, we had produced only a temporary suppression of the discharge, 
still prefer this substance to the nitrate of silver, as we are satisfied that it causes 
less pain. — G. C. B. 



We 

ises 



BLENNORRHAGIA. 71 

of the mucous membrane affected should be discovered, before one 
application can be really topical, direct and limited to the lesion ; 
this may be done, in affections of the glans, the prepuce, and, un- 
der certain circumstances, of the vulva ; but the most common 
form of blennorrhagia, the urethral, does not admit of an appli- 
cation so methodical, so direct ; we should have reason, therefore, 
to apprehend an extension of the inflammation from the applica- 
tion of an irritant to the sound portion of the mucous membrane. 

At one time the sulphate of zinc was much employed ; at pres- 
ent, however, preference is given to the nitrate of silver. Car- 
michael was the first in England, as was M. Debeney in France, 
to highly extol this method to which I shall again refer. 

Besides, it should be well known that the pretension to cut short 
a blennorrhagia is an old one, and that the abortive treatment was 
long since tried,, judged, and condemned. Indeed, Charles Musi- 
tan professed to cure a gonorrhea in three days by injections. If 
we employ them when the purulent discharge first appears, it 
is at once arrested. If they be used before the discharge has 
appeared, whilst the parts suffer from an extraordinary itching, 
the disease is prevented. Astruc, who quotes Musitan, has already 
remarked that unfortunately for the debauchee, both reason and 
experience demonstrated the falsity of this method, and that it is 
possible in place of preventing a gonorrhea sometimes to operate 
when no disease exists.* Finally, Astruc very justly remarks, 
that plrysicians are seldom consulted whilst gonorrheas are forming, 
and still less before they have appeared.^ This passage from As- 
truc is very remarkable. 

For my own part, when there is but a suspicion of congestion, 
or when the inflammation has commenced, I recommend, distinctly, 
rest of the organs, bodily repose, abstinence from food and drink 
which can render the urine irritating, or excite or inflame the 
genito-urinary mucous membrane ; then follow emollients, baths, 
diluent drinks, a diet not too severe, and most powerful antiphlo- 
gistics when the inflammation is really established. If the patient 
is young, vigorous, and the .inflammation very active, very painful, 
I at once abstract blood and thus greatly promote resolution, and a 
decided resolution. I have never found that antiphlogistics, even 
when used for a length of time, produce the chronic state to which 
blennorrhagic discharges too often tend. The contrary I have very 
often observed; I have seen, indeed, that the cases which most readily 
become permanent, are those in which the abortive treatment has 
been tried, and in which violent means have been employed. When 
the symptoms of a decline are apparent, and the violence of the 
inflammation is less marked, I have recourse to anti-blennorrhagics, 
to a combination of cubebs and copaiba. In the last place, and 
when the inflammation is extinguished, if the discharge persists, 
I resort to injections. With regard to the order in which injec- 
tions should be used, I am entirely of Swediaur's opinion. I pre- 
fer astringent to caustic injections, and when I wish to produce 

* T. iii. p. 86. f T. iii. p. 87 



72 VIDAL ON VENEREAL DISEASES. 

the effects of the latter, I prefer the solid nitrate of silver, which is 
more easily managed than the solution of the same salt. I believe 
that it is of great advantage in the treatment of blennorrhagia, to 
isolate, as much as possible, the inflamed surfaces ; thus, in bala- 
nitis, in vulvitis, and in a certain stage of vagnitis, we may with 
lint, or charpie, or wadding, produce this isolation. But such is 
not the case with urethritis ; the tents and foreign bodies which 
we suffer to remain in the urethra, can only exasperate the inflam- 
mation. The same effect would be produced by plugging the 
vagina, in females in whom it is narrow, and whilst the inflamma- 
tion is at its height. ■ The details of the treatment will be particu- 
larly exposed in the following chapter. 



CHAPTER II. 

BLENNORRHAGIA IN THE MALE. 



SECTION" I 
BLENNORRHAGIA OF THE URETHRA. 

Causes. — There are certain predispositions to urethral blennor- 
rhagia in the male which may be called organic ; thus, its 
development may be promoted by the unusual size of the penis, 
a large meatus urinarius, and hypospadias. These conditions 
favor the introduction of muco-pus in the urethra. This is par- 
ticularly the case with hypospadias, which prolongs, so to speak, 
the meatus towards the scrotum, enlarges the opening of the 
urethra, and brings the mucous membrane in contact with that 
part of the vagina in which che humors are collected. These 
etiological notions should prevent us from taking any steps by 
which the meatus shall be increased in size. 

In discussing the etiology of blennorrrhagia in general, I 
endeavored to appreciate the influence of age, temperament, ali- 
ments and certain antecedent pathological conditions. I have 
stated that the direct causes were physical, chemical, or patholo- 
gical. Thus, the passage of a calculus through the urethra, the 
introduction of a catheter, an irritating injection, may all produce 
a muco-purulent secretion. Too frequent connection, or that per- 
formed with organs of disproportionate size, masturbation, men- 
strual blood, cancerous ichor, the lochia, the product of a uterine 
or vaginal catarrh, are among the causes which have been accused 
of giving rise to blennorrhagia. 

I designedly repeat, that specific pus, the pus containing syphi- 
litic virus, is, in my opinion, the most frequent and powerful 



BLENNORRHAGIA OF THE URETHRA. 73 

cause of blennorrhagia. Those authors who have denied that this 
virulent matter may produce a syphilitic blennorrhagia, have ad- 
mitted that it may act as an irritant to the mucous membrane, and 
at the same time that they have denied to it the power of produc- 
ing a primitive syphilitic blennorrhagia, they have acknowledged 
that it may give rise to this disease, but under a secondary form. 
This virus therefore deserves a prominent place among the causes 
of the disease, and this fact should not be forgotten when we come 
to its treatment. Indeed, to render it complete, after anti-blennor- 
rhagics, we should adopt the treatment of chancre, distinctly under- 
standing that blennorrhagia should be regarded as a specific disease. 

Seat. — Attempts have been made to mark the point of the 
urethra affected in the form of blennorrhagia under consideration. 
According to my observation, it is found most frequently at the 
commencement of the canal. Thus, Stoll fixed upon that point 
of the canal which corresponds to the fraenum. Desault speaks 
of the fossa navicularis. In the two criminals dissected by Hun- 
ter, the urethra was somewhat more than ordinarily injected, 
especially towards the glans. Feu Cullerier also mentions the 
fossa navicularis, and lastly, M. Ph. Boyer, having made the 
autopsy of a subject connected with blennorrhagia, noticed a red- 
ness at the anterior part of the canal. Swediaur maintained that 
in all cases, the disease is seated in the fossa navicularis ; accord- 
ing to him, when the inflammation extends to a greater depth, it 
is owing to improper treatment, the sudden suppression of the 
discharge, or to some internal cause. 

The appendages of the urethra have also been designated as 
being the seat of the disease in question. Thus Astruc speaks of 
the vesiculse seminales, the prostate, Cowper's glands, and the 
lacunae of the urethra. William Eondelet believed that in cases 
of virulent gonorrhea, the disease was particuly seated in the 
prostate gland. M. A. Severin points out the kind of lesion of 
this gland ; it is an abscess. It is known that before the time of 
Morgagni, the majority of writers admitted the existence of ulcer- 
ations which secrete the purulent matter, which, in their opinion, 
could not be produced except by a mucous membrane in a solu- 
tion of continuity. The idea of locating the disease in one of the 
glands annexed to the urethra, was suggested by the abundance 
of the discharge. Whatever may be its seat, the anterior part of 
the urethra is really that which is first and most frequently 
affected. At this point, as Benjamin Bell remarked, blennor- 
rhagia in its first stage is seated, from which ; by extension, it may 
invade other points of the urethra, and extend not only to Cow- 
per's glands, the prostate, the vesiculae seminales, the bladder, and 
even reach the kidneys. Blennorrhagia has, therefore, really in- 
volved all the different parts mentioned by authors. But these 
are exceptional cases, complications and accidents. Thus, certain 
inflammations of the prostate gland and bladder, are only com- 
plications of urethral blennorrhagia ; such is also the case when the 
tissues surrounding the urethra become inflamed and suppurate, 
producing abscesses which are called peri-ureihral. 



74 VIDAL OX VENEREAL DISEASES. 

Symptoms and Progress. — Blennorrhagia appears in from one to 
three days after the suspected coitus. "I have observed," says 
Cullerier, the uncle, "what is extraordinary, the discharge com- 
mence the next day, and I have seen it, in two instances, first 
show itself not until a month afterwards." Cullerier, the nephew, 
and M . Eatier, refer to an instance in which the disease did not 
appear until five months afterwards coitus. The following is the 
report of it, given by these authors : " There is, at present, in the 
Hopital des Veneriens, a man aged fifty-eight years, of a good con- 
stitution, accustomed to the enjoyment of excellent health, and 
who never had the venereal disease. One day, together with four 
other individuals who did not suffer, he had connection with a 
woman. Five months afterwards, a blennorrhagia appeared. It 
lasted fifteen days, when the discharge ceased, and he became 
affected with mucous tubercules about the anus, for which he 
required my services. Whence these morbid phenomena ? For 
eight years previously, this patient had had no connection with a 
female, nor had he after that above mentioned."* For myself, I 
can only say, that this case is unique. 

Generally the discharge is not the first symptom which appears : 
some patients experience at first a peculiar kind of itching in the 
anterior part of the urethra, and a feeling of weight in the peri- 
neum ; others have an uneasy feeling in the groins ; some complain 
of general indisposition, and of chills ; cases have been observed 
which have all the symptoms of blennorrhagia, minus the dis- 
charge, constituting, as it were, a dry blennorrhagia, which ordi- 
narily is but a stage of true blennorrhagia. Sometimes, on the 
contrary, the discharge precedes all the other symptoms ; the 
patient perceives stains upon his linen, and yet he has suffered 
nothing. 

But, in the majority of cases, the following is the order of 
events : the patient feels an itching sensation at the commence- 
ment of the urethra, which increases, and soon becomes changed 
to pain, particularly at the moment of urinating ; there follows a 
discharge of a thready, shghtly-troubled humor, which dries upon 
the linen. Astruc observes: "The first oozing from the ure- 
thra is attended with a pleasant sensation, and glues together 
the lips of the meatus."* This humor looks like nasal mucus. 
When it becomes dry, the first jet of urine breaking the mucous 
scab (which is soon formed again), produces acute pain. But the 
lips of the meatus become swollen, and of a redder color ; the 
pain in urinating increases, and as the urine traverses the urethra, 
it gives rise to a burning sensation ; hence the popular name of 
chaudepisse, that of arsure, and internal burning of the penis, long 
ago employed. In proportion as the disease becomes more severe, 
the pain seems to extend more and more towards the neck of the 
bladder ; it may be produced by pressing along the course of the 
canal ; the sensibility and tumefaction of the walls of the urethra 



* Dictionnaire de Medecine et de Chirurgie Pratiques. 
f Astruc, t. iii. p. 2. 






BLENXORRHAGIA OF THE URETHRA. 75 

are found gradually to extend towards the posterior part, and the 
matter discharged comes daily from a more distant point. These 
symptoms showing that urethritis is fairly established, are gener- 
ally observed about the fifth day. Whilst passing urine, the pain 
is most violent ; it is felt strongly in the perineum, and is increased 
when the patient crosses his legs, and during defecation, particu- 
larly if he be affected with hemorrhoids. The emission of semen 
is also painful ; when the inflammation extends beyond the mem- 
braneous portion of the urethra at the moment of ejaculation, a 
lacerating pain is felt. The semen issues, foaming as if overflow- 
ing, and this occurs shortly after the contraction of the muscles 
of the perineum. The erections are painful and frequent in pro- 
portion to the abstinence of the patient. The pain is accounted 
for, by the passage of the urine over an inflamed mucous surface, 
by the inflammation itself, and the obstruction arising from the 
tumefaction of the urethra and the ejaculatory ducts, a tumefaction 
which impedes the emission both of semen and of urine. 

The stream of the urine is modified ; sometimes it is bifurcated, 
and it is always diminished in volume. If the inflammation has 
reached the prostate, a complete retention may follow. 

The ingredients and the color of the discharge vary ; it consists 
of a mixture of pus and mucus, or, as it is now called, muco-pus. 
At first, it is of a whitish tinge, and of the consistence of cream ; 
then it becomes yellow, and afterwards green ; it has a bloody 
tinge in very acute cases. Astruc remarks that the discharge is 
of a greenish yellow color, such as we observe in the last stages 
of pneumonia. The blood may even flow in the form of a ure- 
thral hemorrhage. 

During the progress of the disease, the prepuce and the glands 
become more or less swollen ; the summit of the latter resembles 
a cherry nearly ripe. The tissues subjacent to the mucous mem- 
brane of the urethra, become likewise swollen. The little glan- 
dular bodies in which terminate the ducts of Morgagni, Cowper's 
glands, and the prostate itself, are all sometimes inflamed ; they 
rarely suppurate, particularly the latter gland. The canal feels 
knotty. The abscesses which form here and there open within 
the urethra, or externally, this last termination becoming more 
frequent as we approach the glans. On the sides of the frenum, 
two small collections sometimes form, which always open exter- 
nally. Cases do occur in which the inflammation extends over 
the whole urinary apparatus. 

Erections occur during the progress of a blennorrhagia. But 
when the latter is severe, and the patient is very nervous, these 
erections may become very frequent, painful, and obstinate. 
Then occurs that symptom to which has been applied the name 
of chordee. It is often very troublesome when the patient is in 
bed. During an attack of chordee, the penis is hard, very sensitive, 
sometimes even painful. It preserves its natural shape, or it be- 
comes curved ; in the majority of cases it is bent downwards, 
sometimes to one side, and rarely upwards. Astruc has noticed 
this last curvature ; Benjamin Bell twice observed it; I have my- 



75 TIDAL ON VENEREAL DISEASES. 

self seen it. Chordee may occur at any period of blennorrhagia ; 
but it is found most frequently when the inflammation is com- 
pletely established, in the second stage of Benjamin Bell. It has 
been seen to remain even after the subsidence of all inflammatory 
symptoms. 

Hunter recognized two varieties of chordee, one inflammatory, 
the other spasmodic. In the first, the inflammation is not limited 
to the mucous membrane and the little glands, but it affects the 
reticular tissue of the urethra, into which coagulable lymph is 
effused ; these cells become adherent, the walls lose their pliancy, 
and the canal, no longer able to follow the cavernous bodies in 
their development, assumes the ofhce of a cord, by which the 
curve is maintained ; and hence the curvature of the penis. The 
spasmodic chordee is but a nervous phenomena ; it appears and 
disappears, but at no regular intervals. 

Is there a dry blennorrhagia? According to Swediaur, the 
inflammation of the urethra sometimes becomes so intense, that its 
internal surface and the orifices of the glands which border upon 
it, yield no secretion, as occasionally occurs in inflammation of the 
mucous membranes of the nose and lungs. In a severe catarrh, 
all discharge is arrested. This Fabre denies. He maintains, on 
the contrary, that the inflammation in these cases is not severe. 
A very small number of carefully-observed cases have been re- 
corded, establishing the absence of the discharge with all the 
other symptoms of blennorrhagia. I have really observed cases 
of urethritis without any morbid secretion. Cullerier and M. 
Eatier report a case which is perhaps the most authentic on record. 
But, in my opinion, this form of urethritis is never dry through- 
out the disease ; the discharge is wanting either at the commence- 
ment or towards the end. It was at the latter period that it became 
dry in the instance mentioned by Cullerier.* 

The duration of the principal symptoms of blennorrhagia varies 
from ten, fifteen, and even to twenty days ; when it begins to sub- 
side ; then the patient suffers pain only during the passage of the 
urine, the erections are less frequent, and the matter discharged is 
less in quantity. Besides it turns yellow, then of a dirty white 
color ; it puts on, in fine, the characters of mucus, which denotes 
the most fortunate termination of the disease. But, when after 
the cessation of the principal symptoms, the matter discharged 
does not assume this consistence, this particular elasticity which 
characterizes mucus ; when, on the contrary, the drops easily 
separate, like those of milk, somewhat thickened, we have reason 
to apprehend a chronic state. Then the discharge sometimes 
assumes an intermittent character ; it ceases, still to reappear ; it 
is, as is commonly said, a relapse. It consists sometimes of a single 

* Dr. Beadle reported to the New York Medical and Surgical Society, March *7th, 
1840, the case of a young man, who was under his care twice within the year, for 
an affection of the urethra resembling gonorrhoea in all its symptoms, except 
" there was not the slightest discharge." This patient had impure connection forty- 
eight hours before his attack, and he was cured, in both instances, by an injection 
of Nit. Arg. and mucilaginous drinks. Vide JV. Y. Journ. of Medicine and Surgery, 
Oct. 1840, p. 435.— G. C. B. 



BLENjSTORRHAGIA of the urethra. 77 

drop, which is seen in the morning, if the glans be pressed before 
urinating. The least imprudence in diet, coitus, &c, produces a 
return of the discharge. Occasionally, however, connection with 
a healthy woman causes it for a long time to disappear. In these 
different states, pain properly speaking does not exist, the dis- 
charge seems entirely passive, nothing indicates the least irritation 
of the urethra ; the canal may be said to have contracted a habit 
of an abnormal secretion, which requires no inflammatory conges- 
tion to produce it. This is the blennorrhagia of Swediaur, which 
I have partly described. Generally, then, the urine does affect the 
canal, and the proper relations between the properties of this fluid 
and the sensibility of the urethra, would seem no longer to exist. 

Diagnosis — Here the question of the chancre larve again presents 
itself; I have already discussed it in speaking of blennorrhagia in 
general. [In the text, the author here repeats the observations 
made at p. 62, which we have taken the liberty to omit. — Gr..C. B.] 
Chancre at the commencement of the urethra is distinguished from 
blennorrhagia by the induration, tumefaction, and pain under the 
glans. In separating the lips of the meatus, the ulcerated surface 
may sometimes be detected. The discharge from the urethra is 
small in quantity ; it is badly assimilated pus, rather serous than 
mucous, and generally there is a bubo more or less marked.* 

Like all other forms of blennorrhagia, it is difficult to distinguish 
the simple urethral blennorrhagia, that which is but a catarrhal 
inflammation, from that which is virulent. But still, when in this 
case we can establish a real incubation, when the discharge has a 
tendency to become chronic, we have reason to suspect a specific 
disease ; on the contrary, where it follows excessive coitus, when 
its progress is rapid, the attack almost immediate after exposure, 
if the termination is sudden, rapid, there are strong presumptions 
in favor of a simple blennorrhagia. If, at a later period, syphilitic 
accidents supervene, our diagnosis is rendered certain. 

• Prognosis. — Urethral blennorrhagia is more liable to be followed 
by stricture, affections of the bladder, kidneys, and in the male, of 
the prostate gland. At an advanced age the latter accidents are 
most frequent. Orchitis is the most common of all the accidents. 

Pathological Anatomy. — As the opportunity seldom occurs of 
making the autopsy of a subject affected with blennorrhagia, 
anatomy, on this point, has but little to offer. f 

Accidents. — I have already spoken of chordee and peri-urethral 
abscesses ; the other accidents in part mentioned under the head 
of prognosis, will be examined separately when we come to con- 
sider the consequences of blennorrhagia. 

Treatment. — In speaking of blennorrhagia in general, I have 

* Mr. Henry James Johnson observes {op, cit. pp. 19, 20), that the pain in mat- 
ing water is not so decidedly referred to the navicular fossa, or the orifice, as in 
blennorrhagia. The induration in question, he adds, is found from an inch to an 
inch and a'half from the orifice, is circular, yet flattish, about the size of a three 
penny piece, or less — tender to the touch — and gives to the ringer just the same 
iq pression as is conveyed on pinching up an indurated syphilitic sore upon the 
surface. — G. C. B. 

f Vid. p. 69, for remarks here repeated in the text. — G. C. B. 



78 VIDAL OjST venekeal diseases. 

indicated the basis of our treatment ; I now proceed to enter into 
the details and the methods particularly adapted to the urethral 
blennorrhagia. 

1. Abortive Method and Injections. — The abortive method here 
offers the greatest pretensions ; 1. It proposes rapidly to extinguish 
the inflammation, and thus to prevent the accidents of the disease. 
2. To neutralize the virus and to destroy it in situ. I have 
expressed my opinion of this method in my general remarks on 
blennorrhagia. I have stated that it would be rational at the very 
onset of the disease, before inflammation is really established, and 
at the moment of inoculation. Now, the surgeon very seldom is 
consulted at this stage of the disease. It is only at this period that 
M. Ricord proposes this method ; it is therefore applicable only in 
very exceptional cases. M. Debeney generalizes it and resorts to 
it in all stages of the disease, even in blennorrhea, and according 
to him', none, even of the most chronic cases, resist it when well 
managed. M. Debeney prefers caustic injections. 

A very old, very general, and almost popular reproach against 
injections, is their liability to produce strictures. To this it has 
been replied, that stricture, in reality, is but an inflammation of 
the urethra, which has become too protracted ; and that the best 
method of avoiding this is to cut short the inflammation, in fine to 
effect its absorption. This reply, first made by Benjamin Bell, 
would be unanswerable if we did truly subdue the inflammation, 
or if we only abridged its duration. Now, of this there is but very 
little proof. During an entire year I made use of caustic injections 
in blennorrhagia, and once only did I obtain a cure which did not 
require a week's treatment. In almost all the other cases the cure 
was retarded, and in three a urethritis very rapidly produced a 
stricture, which compelled me to discontinue the injections and 
to substitute in their place antiphlogistics of a decided and energetic 
character. One of these patients was finally cured after a moderate 
dilatation with the yellow wax bougies ; the other two, weary of 
the tedious treatment, demanded their discharge; six left with 
blennorrheas, which I could not cure. Among the latter, several 
have probably suffered from strictures. I have been told that I 
employed the injections hi every stage of the disease, which is 
true ; otherwise I should never have had before me a large number 
of observations. I am convinced that those who would employ 
the abortive method only when the inflammation is about to com- 
mence, will employ it but very rarely, for the reason already given, 
that we are almost always consulted too late. What I have said 
in reference to the prevention of inflammation, I would repeat for 
that of syphilitic infection. Still, even for this purpose we are 
almost always too late. I am convinced that many practitioners, 
instead of treating the first stage of the disease, as they suppose, 
in reality treat different stages, and for this reason, their practice 
differs less than they imagine from that of M. Debeney. ■ 

Therefore I consider the abortive method liable to reproach, for 
instead of cutting short the disease, it produces the opposite effect. 
As to the cases of orchitis, of abscesses, of arthritic and opthalmic 



BLENNORRHAGIA OF THE URETHRA. 79 

inflammations, "which have been attributed to the use of caustic 
injections, I believe the picture has bee a greatly overdrawn. Soon 
I will notice the accidents which even M. Kicord admits. I have 
already mentioned a case where a caustic injection did violently 
inflame the urethra and the bladder, so as to compromise, if not 
the life of the patient, at least the peace of his friends. Further, 
this was the most severe accident which I have observed. But the 
most common accidents, and those most to be apprehended, are 
not of a primary but a consecutive nature ; these are, I repeat it, 
strictures. It is evident that a cauterized, burnt mucous mem- 
brane will undergo a solution of continuity, a kind of ulceration, 
the reparation of which must always be accompanied with a dim- 
inution in the diameter and elasticity of the canal. "What has 
deceived practitioners who believe in the efficacy of caustic injec- 
tions, is, that there really follows, after the pain and immediate 
effects of this method, a suppression of the discharge, a subsidence 
of one of the symptoms of the disease. But with this suppression 
■we have not subdued the urethritis ; it has been rendered dry only, 
and this is but a transient, a temporary effect. Now caustic injec- 
tions are not the only means which can thus suppress a blen- 
norrhagia; the same result may be obtained by the powerful 
agents belonging to a rational or empirical therapeutics of the 
disease. For example, cubebs often produce this effect, and I 
have suppressed the discharge in more than one instance by the 
application of leeches to the perineum. But in the majority of 
cases the discharge returns, and these relapses should be noted and 
acknowledged if we would advance science. 

In my general remarks on blennorrhagia, I have already shown 
that the pretensions of this abortive treatment are very old. I 
have quoted the critical remarks of Astruc. Behold the formula 
of Musitan, which according to the pretensions of the above 
named author, was to cure instantaneously : " Take of plantain 
water eight ounces, in which dissolve some sweet mercury reduced 
to a very fine powder ; agitate them together, and with an ivory 
syringe inject an ounce of this fluid lukewarm, # into the urethra 
three times in a day." 

M. Debeney, in a case which he has denominated, Blennorrhagia 
with irritation of the neck of the bladder, employed the following 
formula : 

^. Nit. Argent. 3i. 
Aq. distill. gi. 

According to M. Debeney the surgeon must himself administer 
the injection ; having first washed out the canal so that the muco- 
purulent matter may not impede its direct action upon the mucous 
membrane ; this wash should consist of a solution of nitrate of 
silver about one-thirtieth of the ordinary strength ; and should be 
allowed soon to escape. Immediately after this another injection 
is made which should be retained in the canal for a minute, if we 
would produce a decided impression. The fluid enters the canal 



30 VIDAL OH" VEKEKEAL DISEASES. 

more deeply by pressing with the fingers towards the root of the 
penis. 

The following is M. Eicord's formula, and his manner of pro- 
ceeding :* 

IJ,. Nit. Argent, grs. xv. 
Aq. distill. §i. 

The patient sits upon the edge of a chair ; the penis is put slight- 
ly npon the stretch, and the extremity of the syringe is introduced 
within the canal. The lips of the meatus should be so pressed as 
closely to embrace the canula. The injection must be sudden ; in 
this manner we take the mucous membrane by surprise, otherwise 
the urethra would close upon itself and oppose the further pro- 
gress of the fluid ; one half of that contained in the syringe is 
sufficient to moisten the whole canal. The patient should be in- 
formed of the sensations which he will be likely to experience, 
lest he attribute to the progress of the disease what is but the tran- 
sient effects of the treatment. This injection produces severe pain, 
the discharge is augmented, a serous, sero-sanguinolent or bloody 
exhalation, appears, and this is soon followed by phlegmonous 
pus forming a swelling in the urethra. The first emission of 
urine is extremely painful, the pains being most intense in that 
portion of the urethra corresponding to the glans ; the stream of 
urine may assume every variety of form observed in cases of 
stricture. These pains may be mitigated, if the patient will urin- 
ate with the penis immersed in cold water, and if he will refrain 
from making any efforts. These accidents subside in the course 
of twenty -four hours ; if the bloody exhalation and suppuration 
continue, the injections should not be repeated until they disap- 
pear. 

In certain patients blennorrhagia ceases suddenly after the dis- 
charge of some globules, the cure is preceded by the discharge of 
a kind of thready mucus which is of short duration. Sometimes 
a greenish muco-purulent matter appears ; in this case we may ex- 
pect that the blennorrhagia will continue. 

If the abortive treatment fail, we find on the third day that the 
characteristics of the disease are reproduced ; sometimes, however, 
it is not till after a longer interval, some five or six days for ex- 
ample, that the discharge re-appears. These are the cases in which 
a complete cure has been supposed to have been obtained, but in 
which there really has been but a suppression of one element of 
the disease, viz. the muco-purulent discharge. The careful ob- 
server who will follow these patients, and closely question them, 
will learn that there remain in the urethra modifications in its 
sensibility, unusual heat, especially at the moment of the emission 
of urine ; sometimes there is a real pain, or an itching sensation, 
with a disposition to urinate frequently. The circumstances show 
clearly, in fine, that a urethritis remains, that there is a dry blen- 

* M. Debeney claims this formula. 



BLE^ T XORRHAGIA OF THE URETHRA. 81 

norrliagia winch will soon exhibit all the characters of a true 
blennorrhagia. 

When the discharge reappears the injection should be repeated, 
if it has not forfeited the confidence both of the practitioner and 
patient M. Eicord admits that the injection of nitrate of silver 
according to the formula which he has so long employed, may 
produce fainting, hemorrhage and retention of urine. Add to 
these, the pain experienced at the moment of injection, and the 
inconveniences of the method are already manifest. 

It should not be forgotten that the abortive method of M. Ei- 
cord does not consist exclusively of injections of greater or less 
violence, but that in addition to them, he recommends the use of 
balsams, of which we shall soon speak. Now, as these balsams 
are given in heavy doses, as they are very powerful, and may of 
themselves speedily cure blennorrhagia, we can comprehend how 
those who have confounded in the same statistics the results of 
M. Eicord's practice with the facts of M. Debeney, have furnished 
a very decided proof of their ignorance of the most common rules 
of true medical statistics. 

What I have stated in relation to M. Eicord's practice, has been 
based upon his lectures reported in the Gazette des Hopitaux. Now, 
I find in his Notes to the second edition of Hunter,* that he ad- 
mits the inconveniences to which we have alluded, and that he 
has almost entirely renounced the use of injections. At present, 
M. Eicord prefers the following formula : 

]J. Aq. Eos. gvi. 

Sulph. Zinc. 
Acet. Plumb, aa grs. xv. 

M. Yenot has tried injections of chloroform ; he has published in 
stances of cure resembling those which we have cited as being fa- 
vorable to the employment of very strong injections of nitrate of 
silver. It is in the commencement, a period in which the practi- 
tioner seldom sees a patient, that chloroform is recommended. 

2. Balsams. — We now come to the consideration of the balsams, 
at the head of which must stand copaiba. This is an oleo-resinous 
substance which is obtained from an American tree, growing in 
the Antilles, which tree has also been elsewhere cultivated. M. 
Guibourt prefers, for internal use, the copaiba of Cayenne. It may 
be administered in doses from ten drops to two ounces in a day. 
Pure and in the liquid form, the copaiba has a prompt and power- 
ful action. But the disgust, the retching and vomitings which it 
produces, have compelled practitioners to employ some correct- 
ives, or adjuvants, in order that it may be tolerated by the stom- 
ach. Combined with magnesia, it has been rendered solid so as to 
be made into pills. It has also been inclosed in capsules. The 
pills when very hard are difficult of digestion, and are sometimes 
passed entire by stool. The same objection applies to the capsules. 

* P. 157. 
6 



82 VIDAL ON VENEREAL DISEASES. 

Besides in this form, it is difficult to give very large doses of co- 
paiba, at least to increase considerably the number of pills and 
capsules without disturbing the stomach. In the form of potion 
it is more sure, but even then it still requires correctives ; these 
I will specify by formulas. The most celebrated is that of Cho- 
part: 

]J. Copaib. 

Spt. Vin. rect. 

Syr. Bals. Tolu. 

Aq. Menth. pip. 

Aq. Fleur. orang. aa § ii. 

Alcohol, Acet. 3 ii. 

With all of these corrections, however, there are some patients 
who cannot tolerate the use of copaiba, even when thus adminis- 
tered. Yet I have seen those who could take it without repug- 
nance ; one of these was almost a gourmand. The above potion 
is given in doses of a tablespoonful, from two to six times in a day. 
At the hdpital du Gros Caillou the following formula of M. 
Gimelle is much esteemed : 

Jfc . Copaib. 3 iii. 

Oubeb. 3 ii. 

Yin. Aromat. § iv. 

This is to be taken in a single dose, having previously shaken the 
bottle strongly. The aromatic wine is intended to prevent vomit- 
ing. 

Copaiba has also been given by enemas, according to the follow- 
ing formula : 



o 



^. Copaib, 3 v. 

Ov. Yitel. 3 i. 

Ext. Op. (gummy), gr. i. 
Aq. § viss. 

Before using the injection of copaiba, a simple lavement should be 
administered, so as to empty the rectum. 

I have been accustomed to combine copaiba with cubebs in the 
following manner : 

I£. Copaib, 1 part. 

Cubeb, 2 parts 

Ess. Menth. q. s. ft. Electuary. 

This forms an electuary, of which about half an ounce is to be 
taken in the course of a day. A bolus is made of this by the 
patient himself, and covered with unleavened bread. He is 
generally cured after having used about four ounces of the above 
electuary, it being distinctly understood that he has been suitably 
prepared by the means which I shall presently indicate. 

Some practitioners begin with small doses of copaiba, which 
they gradually increase, without, however, ever reaching a very 



BLENTORRHAGIA OF THE URETHRA 83 

strong dose. This mode of administration is less efficacious and 
more likely to disturb the digestive organs. 

Patients who have taken copaiba are attacked first by an intense 
thirst, the throat becomes dry, and they drink abundantly. Ac- 
cording to M. Eicord, they must not indulge in drink, that they 
may pass urine less frequently, and this, as it were, will be ren- 
dered more balsamic, more impregnated with the principles which 
it derives from the blood. Copaiba also produces other effects. 
Sometimes it acts upon the stomach in such a manner as to pro- 
voke vomiting by the disgust which it occasions. These vomitings 
now and then occur at a later period, and proceed from another 
modification of the stomach, being then rather the effect of an 
irritation of the ventricle. More frequently the intestinal canal 
suffers, active purgation being produced. Both vomiting and 
purging are sometimes present, in fine symptoms of cholera mor- 
bus. Sometimes, on the contrary, there is constipation. It may 
happen, and this is most fortunate, that the bowels are not unusu- 
ally free. In all these cases the blennorrhagia may be suppressed 
even rapidly, but this result, it must be admitted, is more frequent 
and most complete when the digestive organs have well tolerated 
the copaiba. 

Attempts have been made to explain the modus operandi of this 
substance. The majority of the French school attribute the cure 
to a displacement of an irritation from the urethra to the intestinal 
canal. The Italian school recognizes in copaiba neither an irritant 
nor a specific, but an antiphlogistic hyposthenisant ; instead of 
accelerating and strengthening the pulse, as is generally supposed, 
copaiba, on the contrary, diminishes both its force and frequency. 
According to M. Eicord, there is an element of the copaiba which 
enters the blood, reaches the kidneys, which then secrete urine 
having medicinal properties which produce a beneficial effect upon 
the lining membrane of the urethra. 

This question is of but little consequence, but it is of importance 
to remember that copaiba is the most powerful of anti-blen- 
norrhagics. If it is not often employed it is because it is antipathic 
to most patients, in whom it produces an unconquerable disgust. 

There is an accident which I have not yet mentioned, and which 
may deceive the young practitioner ; it is the affection of the skin. 
This is sometimes an erythema, a variety of roseola, or an urticaria. 
These effects of copaiba are more frequently observed in the spring 
and autumn. In the majority of cases, this eruption, which varies 
in different individuals, is of a simple character and soon disap- 
pears ; however, as it is proved that it does not promote the cure 
of the disease, but that it rather tends to aggravate it, the copaiba 
must then be discontinued and the patient allowed repose, during 
which he may take some acidulated drinks preparatory to sub- 
mitting to the use of some other anti-blennorrhagics. Copaiba, 
combined with cubebs, according to the formula which I shall 
presently mention, very rarely produces this eruption on the skin. 
Let us examine this substance, cubebs, for a moment. It is a 
variety of pepper reduced into powder, having somewhat the odor 



84 VIDAL ON VENEREAL DISEASES. 

of copaiba. It has a hot, pungent, and slightly bitter taste. As I 
have already stated, I often combine this powder with copaiba so 
as to form an electuary. It has also been used both in the form 
of an extract and infusion. The powder, however, is that which 
is most generally employed. A dose of from 2£ to 5 drachms is 
given twice a day. M. Puche sometimes gives as much as 2^ 
ounces in a day. 

Cubebs does not disturb the stomach nor inspire disgust like 
copaiba, it produces vomiting less frequently, and especially, it 
does not purge. Indeed it often gives rise to constipation. Some- 
times the stomach is swollen ; the appetite becomes keen, and nu- 
trition most active ; rarely does it produce cutaneous disease like 
that from the use of copaiba. The powder is placed in half a glass 
of an infusion of lime-tree and orange peel, or it is enveloped in 
bread, or capsules, or coated with sugar in the form of saccharated 
capsules. 

If. Puche 1 s treatment. — The following is his practice in cases of 
acute blennorrhagia. His prescriptions which I here insert, are 
copied from his own writings. M. Puche never administers co- 
paiba before the twentieth or twenty-eighth day from the commence- 
ment of the discharge. 

GUMMY SYRUP OF COPAIBA. 



*•■ 


Copaib pur. 




§ii. 




Ghim. Arab. 




§ ss. 




Aq. 




3 iss \. 




Ess. Menth. 


pip. 


mxxxii. 




Syr. Sacch. 




| xiiss. 



Dose from 1 to l£ and 2 ounces of this emulsion in a day. 

BALSAMIC GELATINOUS BOLUS. 

]£. Copaib. 

Terebinth. Inspiss. aa § iss. 
Cubebs, | hi. 

Dissolve tJie turpentine over a hot-ivater bath, and then incorporate with 
it the copaiba and cubebs ; divide this mass into 100 boluses, which cover 
with gelatine. Dose from 12 to 24 in a day. Two to be taken at once, 
at regular intervals. 

M. Puche administers cubebs according to the following method • 

POWDERED CUBEBS. 

Take 1st day, 2-*- drachms for a dose. 

" 2d " 5" " in 2 doses. 

" 3d " 1 ounce in 3 " 

" 4th " 1^ ounces in 4 " 

« 5th " 1| " in 5 " 

" 6th « 2 " in 6 " 

" 7th " Z\ " in 7 " 



BLENNORRHAGIA OF THE URETHRA. 85 

If the medicine arrest the discharge, says M. Puche, I diminish 
the dose in the following proportion : 



ah 


) 8th da 


y 5 2i 


ounces 


in 7 doses 


it 


9th < 


2 


a 


in 6 " 


it 


10th < 


H 


a 


in 5 " 


ti 


11th < 


H 


a 


in 4 " 


it 


12th < 


l 


a 


in 3 " 


it 


13th < 


5 drachms in 2 " 


it 


14th < 


n 


u 


in 1 dose. 



These doses are to be taken in a well-sugared lemonade at regular in- 
tervals, between meals. 

When the disease is of more than two months standing, and has 
become chronic, M. Puche employs the following injections: 

fy. Nit. Argent, grs.l| 
Aq. dist. | iii. 

An injection every morning and evening for five days* 

1^,. Nit. Argent, grs. iii. 
Aq. dist. | xii. 

An injection morning and evening for five other days. 

M. Puche adds : after these injections have been used for six 
days, the patient is to take no medicine for the next five days. 
Yery frequently the discharge is entirely suspended ; but whether 
it does or does not continue, it is prudent to give the cubebs in 2£ 
drachm doses for eight days. 

Author's Treatment. — The following is my method of treating 
blennorrhagia. I always commence with antiphlogistics, the ac- 
tivity of which is proportioned to the duration and severity of the 
disease. Thus, in the majority of cases, I recommend in the first 
place the use of baths, a soothing tisane, and quietude. If the 
patient is strong and plethoric, and the disease severe and painful, 
accompanied with frequent erections, to the above I add the ab- 
straction of blood ; this is generally effected by the application of 
twenty leeches to the perineum. It sometimes happens that these 
means, aided by a mild regimen, are sufficient, that is to say, in 
about eight days after their use, the blennorrhagia subsides. If 
the discharge continues, I have recourse to indirect anti-blennor- 
rhagics, to copaiba or cubebs, but more frequently to a combi- 
nation of the two in the form of the electuary of which I have al- 
ready given the formula. In conjunction with repose, the baths 
alone, or leeches, this anti-blennorrhagic produces a very speedy 
and powerful effect ; very rarely does it effect the neck of the 

* It will be noticed that this corresponds to the injection which I employ after 
the use of balsams. 



36 VIDAL OX VENEREAL DISEASES. 

bladder in the manner which is observed when antiphlogistics have 
not been previously employed, and when it gives rise to frequent 
dispositions to urinate, to high colored and sometimes bloody 
urine, or by a more or less decided dysury. 

I never resort at once to injections. I employ them only when 
the antiphlogistics, the indirect anti-blennorrhagics, have failed to 
arrest entirely the discharge. Then, only, do I make use of in- 
jections, and these not of a caustic but an astringent nature. The 
following is my favorite formula ; it is old, not very scientific, but 
excellent in a practical point of view : 

^ . Aq. Eos. § y. 

Acet. Plumb. 
Sulph. Zinc, aa grs. viii. 

Shake the vial. At least two, sometimes four injections in tlie day. 

When I employ the nitrate of silver, it is generally as an as- 
tringent, and then I prefer the following formula : 

^ . Aq. Ros. 3 viss. 

Nit. Argent, gr. \ 

When we wish to produce a caustic effect, it is better to use the 
nitrate in a solid state. This may be done with a straight porte 
caustique for the anterior portion of the urethra, and with the 
curved porte caustique of M. Lallemand for the membranous and 
prostatic portions. We should resort to this means only in the 
chronic state, when we have reason to suspect that the disease has 
become seated on a limited extent of the urethra. 

A long and extensive experience, both in hospital and private 
practice, with the method of treatment which I have recommended, 
authorizes me to declare that its results are more certain and even 
more rapid than those obtained by methods which make preten- 
sions to much more speedy cures. It is easy to perceive, that in 
any case it has neither the inconveniences nor the dangers of that 
which is called the abortive treatment. 

There is one phenomenon quite intolerable to the patient, and 
to which I have alluded in the symptomatology of the disease, viz. 
CHORDEE, an inflexible condition of the urethra which does not 
permit it to follow the cavernous body during an erection. Even 
here, in the majority of cases, the first and best means, is the ap- 
plication of leeches to the perineum. Next come the sedatives, 
properly so-called, such as opium, camphor and hyoscyamus. The 
first named are often thus combined : 

3. Camph. 

Ext. Opii. aa gr. viii. 
Ov. Yitel. 3 i. 
Aq. I V. 

For an enema. 



BLENNORRHAGIA OF THE URETHRA, 87 

The following pills are generally preferred : 

^ . Camph. gr. ii. to grs. 6. 
Ext. Opii. gr. -j- to gr. i. 
Mucilag. q. s. 

One, tiuo or three pills a day, commencing in the afternoon. 

Thirty or forty drops of laudanum may also be administered 
when the patient retires, or when the first erections occur. 

Cold applications to the genital organs, to the feet, a walk upon 
the cold marble slabs have sometimes succeeded. The patient 
jumps out of bed, and by walking with naked feet upon the floor, 
is sometimes relieved. But it occasionally happens, that, when 
the patient returns to bed, and becomes warm again, the erections 
are stronger than before. 

The hyoscyamus niger was sometimes successfully administered 
by Benjamin Bell, even when opium had failed. This English 
surgeon gave from one to eight grains of the extract, three times 
in a day ; eight grains being administered after the patient had 
become accustomed to this medicine for some weeks.* But if the 
patient suffered from chordee during all this time, I think it 
would have been better to have resorted to some other means. 

A number of topical applications have also been employed. I 
once succeeded in relieving a chordee with very painful erections, 
by means of mercurial ointment applied along the track of the 
urethra in front of the scrotum. After the employment of fric- 
tions, a thick layer of the ointment was left upon the penis. Com- 
presses dipped in equal parts of cold water and laudanum may be 
applied so as to cover the penis, scrotum and perineum. Brandy, 
camphorated oil, bran and water, have been used in the same man- 
ner. When there is nothing more than an erection, or a spasm 
by which a superficial urethritis is complicated, these means may 
succeed. But when the chordee depends upon an inflammation 
which involves the tissues covered with mucous membrane, when 
plastic lymph is already effused in the cellular tissue, the anti-spas- 
modics and sedatives above mentioned will fail, we must then re- 
sort to antiphlogistics, to local and sometimes to general bloodlet- 
ting, particularly if the patient be young, vigorous, and plethoric. 
Benjamin Bell has proposed, as have other writers, to. depress the 
penis, and to bind it to one of the thighs. It has been recently 
recommended to pull upon the prepuce, to press on its extremity, 
so as to compress the glans and penis by its sheath. These 
means, which may have succeeded where the erections have not 
been very painful, would not only prove ineffectual but might ag- 
gravate a case of really inflammatory and painful chordee. 

Hygeine must be recommended. Thus, the quantity of drinks 
taken should be diminished, and those used should not be of an 
exciting character. The patient should be advised to cover him- 
self lightly on retiring, and to apply cold lotions to the penis. 

* Vol. i. p. 246. 



38 VIDAL OX VENEREAL DISEASES. 

Consequences of Blennorrhagia. — The consequences of blennor- 
rhagia are numerous, as an urethritis may in its course involve the 
whole genito-urinaiy apparatus. I must, however, here confine 
mj remarks to those which are closely allied to the primary dis- 
ease, the others being discussed in every treatise on surgery ; thus, 
strictures of the urethra, chronic affections of the prostate gland, 
affections of the seminal ducts, could not be embraced in this work, 
without disproportionately increasing its bulk. But I will treat 
of blennorrhcea, hemorrhage, and of pains and perverted sensa- 
tions in the urethra; I will afterwards consider the subject of or- 
chitis, prostatites, cystitis, nephritis, arthritis, and blennorrhagic 
ophthalmia, accidents sometimes of a very serious nature, and 
which we should endeavor to prevent, which we must often com- 
bat, and the study of which cannot be separated from the affection 
of the urethra. 

Blennorrhcea. — According to Swediaur, llennorrhcea is a passive 
discharge, (fluxus passivius,) whilst blennorrhagia is an active, in- 
flammatory discharge (fluxas activus). In accepting Swediaur's 
definition, because it is generally admitted, I cannot receive it, at 
least in the majority of cases, in the sense in which it is used in 
English syphilography. Because, in my opinion, blennorrhcea, 
that is to say, the discharge which is generally the result of blen- 
norrhagia, more mucous in its character and less abundant in quan- 
tity, which ceases but to re-appear ; in fine, that discharge which is 
called a gleet, military drop is but a chronic inflammation of the 
urethra with or without a complication of an analogous inflamma- 
tion of its appendages. I have already remarked that this opinion 
should not be received in the most absolute sense, for there may 
be gleety discharges without a previous blennorhagia, that is with- 
out an active discharge. I would not therefore deny the existence 
of a passive discharge, or at least of one which is entirely indepen- 
dent of an actual urethritis or one already extinct. 

It is difficult to name the precise period at which blennorrhagia 
ceases, and a blennorrhcea begins. Some authors maintain that 
the discharge is no longer blennorrhagic but a gleet, when it ceases 
to be contagious, others regard it as a gleet when it is no longer 
troublesome, when the discharge is transparent, and viscous like 
mucus. But it is well-known how difficult it is to establish con- 
tagion from an urethral discharge, and as regards its transparency 
and mucous character, this may change from day to day ; indeed, 
a gleet which to day may be transparent, and mucous to-morrow, 
may be opaque and more or less purulent, and all this may come 
from the least imprudence in regimen. But an examination of the 
causes of blennorrhcea will lead to a better idea of its nature. 

Causes. — The principal and most frequent cause of a gleet is the 
persistence in a chronic form of the urethritis which caused the 
blennorrhagia. For, according to my views, blennorrhcea is 
chiefly a chronic blennorrhagia. Indeed, when after forty or fifty 
days the blennorrhagia does not cease, we have reason to appre- 
hend that it will become chronic. Then, if the patient be care- 
fully examined, as well as the circumstances by which he is sur- 



BLENNORRHAGIA OF THE URETHRA. 89 

rounded, it will be found that lie is of the lymphatic or bilious 
temperament ; or that he has a strumous, rheumatic, dartrous, or 
a syphilitic diathesis. 

According to M. Cazenave, syphilis plays an important part in 
the etiology of blennorrhoea. In his opinion, every slight discharge 
which becomes permanent, is due to a morbid disposition left by 
the virus which first affected the urethra ; blennorrhoea, in fine, is 
but the remnant of a virulent blennorrhagia imperfectly cured. 
If no particular diathesis or vice exist, it will be found that the 
patient has not submitted to hygienic rules ; during the treatment, 
and the decline of the blennorrhagia, he has not observed the 
necessary repose, and has indulged in improper aliments and 
drinks, and sexual intercourse, or masturbation. Among my city 
patients, the discharge is maintained by the presence of a com- 
panion, near which the patient cannot remain without excitement ; 
and in hospital practice, I have had opportunities of knowing that 
the very youngest of those affected with an obstinate discharge 
were inclined to masturbation. 

In the etiology of this disease, we must not omit the influence 
of the absence of all treatment, or of improper treatment. In 
speaking of the therapeutics of blennorrhagia, I have designated 
as a cause of chronic urethritis the so-called abortive treatment, 
because it is that which most frequently fails, and which has the 
strongest tendency to render the disease protracted. 

If we take a general view of the causes, we find that they are 
of two kinds, the one pertaining to diathesis, the other irritant, 
excitant. * The first gives a chronic and specific character to the 
disease, rendering it exceedingly rebellious to treatment; these 
are, therefore, complicated cases, for to the inflammatory element 
there has been added the rheumatic, the dartrous, the strumous, or 
syphilitic. The obstacles in the way of treatment may already be 
anticipated, obstacles which will render it especially difficult when 
they depend upon a complication with a peculiar diathesis. Thus, 
there are patients with dispositions to catarrh, to discharges with- 
out provocation, from the ears, nose, and eyes, which, once affected 
with blennorrhagia, never get rid of the disease. These are the 
patients who may have a primary or non-consecutive gleet (cTem- 
blee), that is to say, a blennorrhoea which has not been preceded 
by a blennorrhagia. A neglect of hygiene is chiefly the exciting 
cause. The patient devotes himself too much to his occupations, 
is guilty of luxurious indulgences, and makes not a proper selec- 
tion of his aliments. 

Seat and Anatomical Characters. — I have already shown that the 
part first involved in blennorrhagia was the commencement of the 
urethra, in the vicinity of the glans. The most common seat of 
blennorrhoea, on the contrary, is towards the end of the urethra, 
in the region of the prostate. M. Baumes is very explicit upon 
this point. However, blennorrhoea has been observed, in which 
the disease was less profoundly seated ; there are some cases, even, 
in which the seat is the same as that of an incipient blennorrhagia ; 
indeed, it happens that an urethritis becomes chronic in the same 



90 VIDAL ON VENEREAL DISEASES. 

situation in which it has been primarily acute. Of this I am cer- 
tain, for by the application of the nitrate of silver to the fossa 
navicularis, I have removed the most obstinate cases of blennor- 
rhoea. When the latter is symptomatic of stricture, it is generally 
towards the curve of the urethra that we find the most important 
lesion, viz. a thickening or induration of the sub-mucous cellular 
tissue. Sometimes it is difficult to decide upon the seat, the ana • 
tomical characters of blennorrhcea ; in these cases, there is that 
disposition to mucous discharges of which I have spoken in treat- 
ing of the causes of the disease : the mucous membrane of the 
urethra may here preserve its natural appearance, like that of the 
nose, which presents nothing abnormal, even in a state of well- 
marked hyper-secretion. 

Symptoms. — The discharge in gleet is not always constant; 
sometimes there is a kind of intermission : it thus happens that 
the meatus urinarius is always moist, that the linen in contact 
with it is always more or less stained, or that the discharge appears 
more particularly at certain periods ; this may be in the morning, 
after slight exercise, or a repast. In some cases, it is only by 
pressing the urethra from behind forward, that the discharge is 
brought in this direction ; this is the case when it is deep seated 
in the canal. Then it is thick, viscous, and small in quantity ; 
being carried away from time to time by the urine, it is rarely 
observed at the meatus, or if here perceived, it is only in the 
morning, when no urine has been passed during the night. If its 
seat be the fossa navicularis, we may in a manner produce the 
discharge at pleasure ; we have but to press upon the glans, which 
is then often very sensitive to this pressure. It is a little en- 
gorged ; one or both lips of the meatus are sometimes of a violet 
color ; and in separating the lips, the urethra appears of a violet 
red. If the seat of the discharge be more deeply situated, the lat- 
ter may be perceived without resorting to pressure, but for this a 
certain quantity of the discharge is necessary. Thus the quantity, 
consistence, viscosity of the humor, the more or less frequent dis- 
charge of the urine, may exert an influence upon the manner in 
which blennorrhcea presents itself to the observer. In every 
case, the different positions of the penis must, more or less, favor 
the appearance at the meatus of the gleety discharge. 

The humor may be entirely transparent and viscid, as described 
by Benjamin Bell, when it is supposed to be no longer contagious, 
it may be of grayish or milky white color ; and the pus is more or 
less combined, or more or less separated from the mucus. The 
stains on the patient's linen are generally of a pale yellow color ; 
sometimes scarcely visible ; they are of a grayish white color ; 
generally the central point is more deeply colored, the rest being 
very clear. Sometimes the stained linen has a sickly, sourish odor. 
Hunter maintained, that when the globules of pus, instead of float- 
ing in the serum, are suspended in a thready mucus, the discharge 
is no longer contagious. M. Baumes is less confident; according 
to the physician of Lyons, when the discharge is simply mucus, 
transparent, limpid, without color, thready, and glairy, it then less 



BLENJN T ORRHAGIA OF THE URETHRA. 91 

frequently possesses contagious properties, but even with these 
characters, when it would seem to be deprived of all purulent 
globules, the discharge may still be contagious ; the only difference 
being that contagion under these circumstances is less frequent. 
Blennorrhcea, in general, is not painful; the sensibility of the 
urethra, however, is not normal ; the patient complains of itching 
in the canal towards the perineum, or there is a feeling of weight 
or vermicular sensation extending from the urethra to the rectum, 
which the patient refers chiefly to the latter situation. Sometimes, 
indeed, it is on account of this annoyance, and not for any affection 
of the urethra, that we are consulted. Most generally he is of the 
opinion that he is troubled with ascarides in the rectum. I repeat 
it, that in blennorrhcea there is an absence of pain, properly speak- 
ing ; and when, as the result of excesses, it is present, it is felt in 
the vicinity of the gland, at the moment when the urine reaches 
the fossa navicularis, or when the last drops are voided. In such 
cases chronic inflammation exists in the anterior part of the canal. 
The same pains may exist when the urethra, is inflamed at a greater 
depth, which is the most common seat of the lesion in cases of 
long standing. Then, in addition to pain, there is a frequent dis- 
position to urinate ; the urine contains more or less of deposit, and 
there are symptoms of inflammation of the neck of the bladder. 

Diagnosis. — The diagnosis of blennorrhcea is generally not difn- 
cult. The only difficulty is in distinguishing cases in which the 
discharge is from those in which it is not contagious. What may 
most confidently be asserted is, that when the discharge is entirely 
mucous, free from pus, contagion is least to be apprehended ; but 
it is a more dangerous doctrine that when the discharge is of the 
above character, that for a long time it could not have been con- 
tagious. It is evident that many very obstinate cases of gleet, in 
which the discharge is thin and milky, and sometimes even colored, 
in all its shades and degrees of consistence, are entirely innocent, 
and that females have escaped after intercourse with those affected 
with every kind of gleety discharge. But notwithstanding these 
facts, which are very numerous, exceptions have been observed, 
which have given rise to much domestic unhappiness. I know of 
two cases of contagion from gleet ; the disease was considered as 
of no consequence, and marriage, under the circumstances, was 
permitted ; separations were the result. One of the infected women 
gave birth to a child, which succumbed in three months, covered 
with pustules. Thus the greatest uncertainty attends our means 
of distinguishing a contagious from a non-contagious case of gleet, 
and the practitioner should always inform the patient affected with 
it, who consults him upon the subject of matrimony, that the dis- 
ease is contagious.* 

* The judicious advice here given by our author accords, we believe, with the 
sentiments of the majority of the most experienced British and American practi- 
tioners. "We have, however, nowhere seen this common sense view of the subject 
more happily expressed, than by Mr. Skey, in his Lecture on Gonorrhoea, in the 
Lond. Med. Gazette, June 1839, p. 443. "Applications are frequently made for the 
purpose of ascertaining at what period of the disease it ceases to be communicable. 
I recommend you to be most cautious how yon commit yourselves on this head, by 



92 VIDAL ON VENEREAL DISEASES. 

Prognosis. — Blennorrlioea, being in the greater number of cases 
a chronic urethritis, the seat of which is in the deeper portion of 
the canal, where the openings of the seminal canals touch the 
prostate gland and neck of the bladder, we can understand how, 
from any excitement or irritating cause, this inflammation may 
extend to the vesicuhe seminales, the bladder, and the prostate 
gland. Thus, it is not unusual to observe disturbance of the func- 
tions of the vesiculae seminalis, such as nocturnal or diurnal emis- 
sions, the consequence of the inflammation which has been propa- 
gated from its first seat, the urethra, to the adjoining parts. More 
than one vesical catarrh has been caused by an aggravated blen- 
norrlioea. Prostatic engorgements are often thus produced ; a fact 
which is incontestable in the adult. In old men it may proceed, 
as is well known, from spontaneous hypertrophy, without previous 
inflammation of the urethra. But to maintain, as does M. Mercier, 
that urethritis has no connection with this hypertrophy, is more 
than is warranted by the facts of the case. I believe, on the con- 
trary, that in the prostatic engorgements of old men urethritis 
plays an important part. If, in our inquiries into the history of 
the case, it is not found, it is sometimes owing to the fact that it 
occurred before, or at a forgetful age, or that the patient is un- 
willing to admit certain details. The prognosis in blennorrhoea is 
therefore serious, as regards the connection of a female with a man 
thus affected, and the health and constitution of the children which 
may spring from such connection, and as regards the patient who 
is himself diseased. 

I have already alluded to the dangers of an urethritis when it 
becomes extensive ; it is to be dreaded even when it is concen- 
trated on a limited space ; for then strictures may result from the 
engorgement and condensation of the sub-mucous cellular tissue. 

A gleet, even when there are no apprehensions of contagion, and 
when it does not interfere with the functions of the genito-urinary 
apparatus, may exert a deplorable influence on the spirits of the 
patient. It seems difficult to comprehend how the appearance of 
a single drop of discharge, in the day, at the meatus urinarius can 
so affect the mind of the patient. Those who have often been 
consulted by persons affected with venereal disease, know the 
despair which is felt by certain patients, and must possess letters 
written by them, in terms most melancholy. Others, again, are 
perfectly indifferent to this disease ; such are the most dangerous 
as regards the female sex. 

Treatment. — In the treatment of this disease we should take into 
consideration all the causes which have been enumerated as con- 
cerned in its production. But our practice should be chiefly based 
upon the idea which I have constantly endeavored to keep in 

which, in case of failure, you render yourselves morally responsible for whatever 
consequences may ensue. In truth we know nothing about it. What is communi- 
cable to one person is incommunicable to another; and so long as we have no cer- 
tain evidence by which to draw the line, it is better to adopt the alternative of 
declining an opinion altogether, or of leaning to the side of good morals, by declaring 
that, so long as discharge exists, there is no exemption from the liability to com- 
municate it." — G. C. B. 



BLENNORRHAGIA OF THE URETHRA. 93 

view, viz. that we liave to contend with an urethritis. Every 
practitioner acquainted with this fact, may calculate upon success 
much more frequently, and much more confidently than can he 
who is impressed with an opposite opinion. Thus, for my own 
part, the basis of my treatment of blennorrhoea is identical with 
that of blennorrhagia. In both affections it is the urethritis which 
I combat. Especially do I conform to this doctrine when blen- 
norrhagia has not been treated, or, in cases where it has been 
improperly treated, if antiphlogistics have not been employed in 
the first place, if hygienic rules have not been observed during the 
treatment, and if the disease has not been improved. In cases 
where these measures have been employed, and these rules ob- 
served, I do not insist upon the use of antiphlogistics, but resort to 
direct astringents, to derivations, in fine to the means which are 
generally used to combat a blennorrhoea, not as a symptom of 
inflammation, but as a disease essentially catarrhal. 

This is not the place to prescribe the rules of treatment adapted 
to every constitution, to every diathesis. I will only remark, that 
when we have reason to suspect the rheumatic diathesis, a change 
of climate, a dry and warm residence, the vapor bath, aloetics, are 
calculated to produce beneficial results. It is particularly in pa-, 
tients of this class, that we observe cases of blennorrhoea cured by 
horse-back exercise, the excitement of the chase, or a voyage to a 
warm climate, especially where a suppressed perspiration has been 
made to reappear, or a new one established. If the strumous dia- 
theses is suspected, we must resort to the preparations of iodine. 
In this category should be classed the patients who are cured by 
salt bathing, a remedy so highly extolled by Hunter. When 
blennorrhagia is complicated with a dartrous vice, and runs into an 
obstinate blennorrhoea, saline purgatives should be repeatedly em- 
ployed, an irritating regimen avoided, and all diffusible stimulants, 
without, however, prescribing tonics properly so called. When blen- 
norrhoea exists in a patient affected with eczema, or who has the 
mucous temperament of which I have spoken, I have recourse to 
the internal administration of ferruginous preparations : as for ex- 
ample, the pills of valette, or the saccharated ferruginous pills made 
according to my own formula. Each of these contains about one 
grain of the lactate of iron. At first, I give three in a day, and 
the patient may take as many as six or eight in a day if the 
stomach tolerate, and if there be not obstinate constipation.* De- 

* With Mr. Skey (Lect. cit. p. 443), we are satisfied that in many cases of gleet 
it is necessary to raise the standard of the circulation, and nervous power, by re- 
suming ordinary diet, and ordinary stimuli. " If," says this surgeon, " you treat a 
person habitually prone to large libations of drink, by entire desistence from his 
ordinary and necessary stimulus, he will have a protracted gleet; and this prin- 
ciple holds in all cases, cceteris paribus, in which the depletion, whether positive or 
negative, has been needlessly persisted in ; therefore, the first consideration applies 
to constitutional treatment, which is, at least, equally important to local. I re- 
cently had a man under my care, who, when in health, took per diem about one 
gallon of porter, in addition to an occasional glass of gin. He had been the subject 
of gleet for ten months, for which he had employed the usual catalogue of local 
remedies. I desired him to leave the gleet to take its own course, and resume his 



94 VIDAL OX VENEREAL DISEASES. 

rivatives, such, as blisters, cauteries applied at a greater or less dis- 
tance from the urethra, should be preferred in cases complicated 
with the rheumatic or dartrous vice. Benjamin Bell greatly ex- 
tols the efficacy of blisters applied to the perineum. Eecently 
this practice has been revived, even in the acute stages of an ure- 
thritis. In blennorrhagia they can be applied along the track of 
the urethra, in front of the scrotum. But as they have been used 
in conjunction with, or immediately after certain injections, it is 
difficult to decide upon their agency in effecting a cure. They 
should always be regarded as means to be employed after others 
which are less painful and attended with less inconvenience. If 
there be reason to suppose that blennorrhoea is a primary syphil- 
itic accident which has become protracted, or that it is a consecutive 
accident, the general treatment for syphilis should be pursued. 
Both the direct and indirect anti-blennorrhagics must necessarily 
be employed in the management of blennorrhoea ; as for example, 
cubebs and copaiba. If the disease is the result of a marked blen- 
norhagia, that is to say, one which could not be cured, either from 
wrong or improperly-directed treatment, then after the application 
of leeches to the perineum, and along the course of the antiscrotal 
portion of the urethra, a combination of copaiba and cubebs in the 
form of the electuary already mentioned, may be administered. 
But a blennorrhoea cannot be removed like blennorrhagia, and 
these means continued for a length of time in the doses specified 
may singularly disturb the digestive organs ; in such a case the 
dose must be diminished, or the medicine must be for a time sus- 
pended, or turpentine substituted, of which the patient may take 
one drachm in the day. If the stomach is still intolerant, we must 
resort to injections. An immense variety of these have been em- 
ployed. Here I recapitulate the formulas which. I have used in 
blennorrhagia : sometimes I inject 5 ounces of water with 8 grains 
of the sulphate of zinc and acetate of lead ; sometimes I employ 
the nitrate of silver in the strength of 2 grains to 3 ounces of 
water. 

Injections should be more frequently repeated here than in 
blennorrhagia. In certain obstinate cases, we inject not only 
twice, or four times, but even more frequently during the day. 
My success in more than one case has been owing to the use of 
astringent injections thus repeated. I prefer, therefore, the injec- 
tions of the sulphate of zinc and the acetate of lead. Sometimes 
I have used cold water alone. "We may also employ the follow- 
ing formula of Benjamin Bell : 

I£ . Sulph Zinc, § ss. 
Eau. dist. 3 viii. 

usual drink. He perfectly recovered in a week, and has had no return of the 
discharge." 

Mr. Henry I. Johnson {op. cit p. 103), after alluding to the fact that gleet is 
often cured by the most inconsistent treatment, remarks, that after all, these cases 
resolve themselves into the following formula : — that gleet, being a morbid action 
in the part, slight in itself, but sustained by habit, may be cured by any thing 
which excites a new action, and so breaks that habit. — G-. C. B. 



BLENNORRHAGIA OF THE URETHRA. 95 

Or this : 

^ . Sulph. Alum, et Potass, grs. xv. to xxx. 
Eau. dist. § ii. 

Vinous solutions of vegetable astringent have been much em- 
ployed, according to the following formulas : 

^ . Yin. (heavy red) g ii. 
Tannin pur. gr. i. 

Yin. (heavy red), § ii. 
Quinquin, rub. 3 i. 

Macerate for 48 hours. 

It has also been proposed to act by injections upon the cause, 
the diathesis which protracts the blennorrhea. In supposed scro- 
fulous cases, M. Kicord has experimented with injections of the 
iodide of iron (one grain to the ounce) ; then he has increased the 
strength to 18 grains to the ounce. Certain patients with a thick 
discharge, have been cured in four or five days. In others, these 
means have rekindled the acute stage ; instead of a muco -purulent, 
there has been a discharge of bloody serum, and when the injec- 
tions have been discontinued, the blennorrhoea has been removed. 
Other patients have been irritated, and not cured. It is very pro- 
bable that these iodurated injections have acted simply as irritants, 
and not as specifics against a diathesis (antidiathesiques). 

The mildest injections may so irritate the canal as to oblige the 
practitioner to suspend them for awhile, and to resume their use 
after an interval of some days. If the irritation should reappear, 
and especially if in a severe form, injection must be proscribed, or 
at least the formula which has excited it. 

It often happens, when a preliminary treatment has been 
adopted, and the injection well selected, that the discharge is" 
lessened, in which case we should continue its use until it has 
completely ceased. Even after this occurs, as many as ten have 
been employed, at intervals of from two to three days. Some- 
times, without augmenting the urethral irritation, and reviving 
the inflammation, the first effect of the injection is to increase the 
discharge. Then, after four or five days use, they should be sus- 
pended. If, after this period, we observe a diminution of the 
weeping, the injections should be resumed, and it is very probable 
that they will be followed by complete success. 

I have already remarked, that caustic injections have been em- 
ployed not only in the acute stage in blennorrhagia, but in the 
chronic state in blennorrhoea. It then often happens that after 
the immediate and primary effects have passed, the gleet disap- 
pears. But be not deceived ; the disease may then be only 
masked; there may be a dry blennorrhagia, a urethral inflamma- 
tion without secretion, which, in subsiding, will reproduce its 
effects, which have only been postponed ; for the cause being- 
renewed, that is, the irritation of the urethra being brought back 



96 VIDAL ON VENEREAL DISEASES. 

to its first condition, it will give rise to the same discharge, with 
the same, if not still more obstinate characters. 

I do not proscribe caustics in the treatment of urethral dis- 
charges, even where they depend upon an inflammatory condition, 
for analogy compels me to admit their use, and clinical observa- 
tion has furnished me with facts in support of this analogy : thus, 
a slight cauterization of the anterior, or deeper portion of the 
urethra, is a rational practice ; for then we act only on the part 
affected ; in certain opthalmic inflammations, for example, we in 
this manner modify the condition of the conjunctiva. When the 
part diseased in blennorrhoea is deep seated, it is difficult to 
ascertain its situation so as to attack it, and it alone. Before 
employing the porte caustique, we must explore the canal with the 
ordinary sound, or bougie. When the instrument comes in con- 
tact with the inflamed or indurated part, the patient experiences a 
severe pain, and the surgeon feels an impediment to the passage 
of the sound ; it is irregular, encounters slight obstructions, and 
an uneven surface. I acknowledge that this exploration is not 
easy; it requires long practice, but it may be attained. M. 
Baumes, for example, constitutes it a guide to his practice. We 
must not confound the sensations mentioned, those on the part of 
the patient and the surgeon, with those produced at the moment 
when the sound passes through the curve of the urethra, or when 
it enters the bladder, reaching too far into its cavity. When once 
the irregular and sensitive point is felt by the operator, its distance 
from the surface should be marked upon the jporte caustique, and 
the latter should be introduced within the urethra. The cup con- 
taining the caustic having been protruded, it should be turned 
rapidly upon its axis, so that it may act upon the circumference 
of the canal. The caustic is then withdrawn into the sound, and 
the latter is immediately removed. After this trifling operation, 
a bath should be directed, and should be repeated at intervals of 
two, three, or four days, according to the effect produced. 

Sometimes bougies are employed, which have been coated with 
an ointment more or less irritating, or sedative ; thus, an ointment 
of the nitrate of silver (1 grain of the nitrate to 1 drachm of lard), 
or of camphor, may be used. Now and then I have been success- 
ful with the following : 

j^,. Uugt. Hydrarg., 1 part. 
Ext. Bellad. 2 parts. 

Occasionally the mercurial ointment, or the mercurial cerate, is 
relied upon alone. The naked bougie has also been employed ; in 
this case, it acts as a physical agent, modifying the sensibility of 
the urethra, and tanning, as it were, the mucous membrane, and 
thus changing its mode of secretion. Sometimes I have adopted 
this practice with the greatest advantage ; this was especially the 
case in two instances, where the patients in the higher ranks of 
society suffered so much from mental despondency as to consider 
life as a burden. I generally use the yellow wax bougie. Blis- 






BLENNORRHAGIA OF THE URETHRA. 97 

ters to the perineum, and the use of bougies, were regarded by 
Benjamin Bell as our most efficacious means of treatment. This 
practitioner insists upon the employment, and prescribes rules for 
the use, of the bougie. According to him, we should select very 
soft bougies, which will slightly stimulate the parts, without excit- 
ing an inflammation ; they are often extremely useful, not only in 
thus stimulating the weakened parts, but supporting them by 
their volume and their form; they are attended with less risk 
than injections, even when they stimulate beyond our expecta- 
tions, for the inflammation thus excited is always accompanied 
by a temporary discharge, which is well adapted to prevent any 
unpleasant consequences, which might otherwise result from their 
use. The bougie should be as large as the capacity of the urethra 
will admit. Benjamin Bell maintains that it is particularly essen- 
tial in this variety of discharge, that the bougie should be of a 
large size, for it is chiefly from the volume of the instrument that 
success in these cases is attained. We generally ascertain, in the 
course of a few days, whether the bougies are likely or not to be 
useful ; nevertheless, we should not expect any lasting advantage 
unless their use be for a long time continued. In cases of long 
standing, they must be employed for ten or twelve weeks, and 
they should not be discontinued until the cure is complete. It is 
well, however, to observe, that when we have pursued this method 
of treatment for a reasonable length of time, it should occasionally 
be suspended in order to ascertain its effects. When bougies are 
daily introduced, it is impossible to decide whether the discharge 
proceeds from disease, or from the irritation excited by the instru- 
ments ; a bougie cannot remain for a length of time in the urethra 
even of a sound person, without being covered, when it is with- 
drawn, with pus or muco-purulent matter. 

It is better to use the bougies three or four times in the day, 
and not to leave them in the urethra more than ten or fifteen 
minutes. Sometimes, the discharge is not only increased by these 
instruments, but a true blennorrhagia is produced, especially when 
they are allowed to remain in the canal ; in such a case, their use 
should be suspended ; particularly, if they have given rise to fre- 
quent disposition to urinate, or to symptoms denoting an inflam- 
mation of the neck of the bladder. When the inflammation has 
been subdued, we should notice whether the discharge has com- 
pletely ceased. If it has not, we may resort to them again, though 
cautiously. Particularly should we guard against passing the 
instrument too deeply ; a practice of which patients and young 
practitioners are often guilty. 

A gleet which has resisted every kind of treatment, occasionally 
disappears in an unknown manner : sexual intercourse has pro- 
duced this effect. Finally, there are some cases which resist 
everything, even time, and which, after having been symptomatic 
of a form of inflammation of the urethra, are found at length to 
be maintained by strictures, disease of the prostate or bladder, or 
they are complicated with seminal emissions. The treatment, then, 
should be modified according to the complications of the case. 

7 



98 VIDAL ON VENEREAL DISEASES. 



STRICTURE. 



As we are at present concerned with stricture only as one of 
the consequences of blennorrhagia, we shall not dwell upon other 
points in its etiology. Frequently there exists but a single stric- 
ture, though we occasionally meet with more ; thus, M. Lallemand 
refers to the case of a captain Foltz, who had seven ; Collot* met 
with eight, and John Hunterf six, in a single patient. As the lat- 
ter surgeons were deprived of our present means of exploration, we 
may reasonably doubt the accuracy of their diagnosis. No autopsy 
has ever revealed a large number of strictures in a single subject. 
Yet, it is well established, that in many cases, more than one exists. 
M. Leroy d'Etiolles asserts that in nearly one-half of those examined, 
two strict ares are found, within about three lines of each other. 

Seat. — Differences of opinion have prevailed in reference to the 
seat of strictures. This has arisen from the different estimates 
formed of the length of the urethra, the result of different modes 
of measuring this canal. As a general rule, it may be stated, that 
the most common seat, is at the various points of projection of 
the canal, or in the vicinity of these projections, as for example, at 
the seat of junction of the bulbous and membranous portions of 
the urethra, and particularly at the commencement of the latter 
portion ; again, we find stricture occurring at the union of the lat- 
ter with the prostatic portion, and lastly, at the navicular fossa 
and meatus. They may exist at any of the intermediate points. 
Soemmering denies the existence of stricture in the prostatic por- 
tion of the urethra ; Hunter does not dispute such an occurrence, 
but remarks that it has never come under his observation. Prof. 
Lallemand is opposed to the views of Soemmering. Of 14 cases 
reported in the work of the former surgeon, allusion is made to 
strictures situated at the depth of six inches or more from the 
meatus; now, the average length of the urethra being from five 
inches four lines to seven inches three lines, we are compelled to 
admit the existence in these cases, of strictures in 'the prostatic 
portion of the canal. 

[The measurement of the urethra, as made by the following 
surgeons, twenty in number, gives an average of 7-i i u - to 9J 
inches instead of 5J inches to 7^, as stated by our author. 

In. In. 

Amussat, - - 7 to 8 Lallemand, 

Boyer, - - - 10 " 12 Lisfranc, 

Begin, - - - 7i " 9i Meckel, 

Belmas, - - - 10 " 12 Malgaigne, 

Cloquet, I. - - II " 11 Mercier, 

Cloquet, H. - - 9 " 11 Perreye, - 

Civiale, - - - 5 " 7 Sabatier, 

Ducamp, - - 7| " ' 91 Segalas, 

Guthrie, - - 8 " 11 Velpeau, 

Gross, - - - 7 " 12 Whately, - 

Mr. Miller states in his Practical Surgery, (London ed., p. 519,) 
that the ordinary site of stricture is between six and seven inches 

* Traite de Voperation de la taille et des Suppressions d'urine, 1762. 
f Traite des Maladies veneriennes, with Notes by M. Ricord. 



In. 


In. 


7* 


to 9i 


9 


" 10 




8 


5j 


« u 1 


6 


" 10 


L0 


" 12 


8 


" 9 


5 


" 7 


ft 


"9h 



STRICTURE. 99 

from the orifice, in front of the membranous portion of the ure- 
thra, which, with the estimates given above of the length of this 
canal, is far more liberal than that of our author. Indeed, accord- 
ing to the calculation of the latter, Mr. Miller would make the 
prostatic portion of the urethra the ordinary seat of stricture ! 
That this portion of the canal is sometimes the seat of true stricture, 
is positively asserted by M. Kicord, {Notes to Hunter, 2d ed., p. 
217,) in proof of which he refers to the case reported and deline- 
ated by Mr. Crosse, to which, he observes, many others might be 
added. Doubtless it does occur, though rarely, at this point. — 
Gk C. B.] 

The most common seat of stricture is a little in front of the junc- 
tion of the membranous with the bulbous portion of the urethra. The 
following results were obtained by Ducamp by means of his gradu- 
ated instrument : In 5 out of 10 cases, the stricture was encountered 
in from three and a half to four and a half inches, and to be more pre- 
cise, in 4 out of 5 cases it is from four inches ten lines to five inches 
seven lines, from the meatus. It is evident that this would bring it 
in the vicinity of the urethral curve, which, with the exception of the 
meatus, is the narrowest portion of the urethra. At the meatus, 
strictures are not uncommon : I have seen them produced by 
chancres, which had destroyed the frenum, or spent their ravages 
on the summit of the glans. Should the destruction by these ul- 
cers have been more complete, so as to destroy a portion of the 
penis, stricture occurs at the point where the urethra may have 
been divided. The meatus has likewise a tendency to become ob- 
literated, when chancre produces a perforation of the inferior wall 
of the urethra at the navicular fossa, by which a kind of hypos- 
padias is formed. 

Form. — A stricture occasionally presents the appearance of a 
slightly -projecting line, over which the mucous membrane seems 
only to have lost its elasticity and transparency ; sometimes, on 
the contrary, the thickening of the parts is considerable ; all the 
tissues which enter into the formation of the urethra become in- 
volved, thus producing a decided tendency to its obliteration. 

The extent of a stricture may greatly differ, being from that of 
the thinnest fold of the mucous membrane, to one and a half 
inches (Lallemand, sixth case) ; ten to fourteen lines (Segaias), 
and one inch, nine lines ; or two inches, eight lines (Hunter, 
Chopart and Charles Bell.) 

The longest strictures are generally found at the spongy portion 
of the urethra. Sometimes they are of considerable thickness,, 
their dimensions in other respects being not very extensive. In 
such cases a stricture may be mistaken for a fold, a valve, or some 
morbid growth. 

This disposition is particularly frequent at the commencement 
of the urethra, in the vicinity of the glans ; its direction is likewise 
more perpendicular to the axis of the canal. A case is reported 
in the Gazette Medicate, 1840, in which a valve existed in the ure- 
thra, its free margin being directed towards the bladder, thus 
causing an obstruction to the passage of the urine. The patient 



100 VIDAL ON VENEREAL DISEASES. 

was sixteen years of age, and this growth was supposed to be 
congenital. A stricture, which involves but a portion of the cir- 
cumference of the urethra, may be situated on its upper, lower, or 
lateral walls. The latter interfere less with the evacuation of the 
urine, because the opposite point being sound, is easily dilated ; 
this variety is also most liable to exist a long time undetected, for 
it does not, except when excessively developed, oppose the intro- 
duction of the catheter. No instances of a perfectly longitudinal 
stricture have yet been discovered. 

M. Amussat maintains that the urethra is never perfectly oblit- 
erated ; he asserts that a communication always exists between 
the parts anterior and posterior to the obstruction. Any inter- 
ruption to this communication, is, in his opinion, but temporary, 
and is caused by some foreign body. 

It was doubtless through inadvertence that Eicherand asserted, 
that of 10 cases of retention of urine, 8 are due to an obliteration 
of the urethra.* The truth is, that these obliterations have fre- 
quently been supposed to exist, when they were absent, or only 
caused by accidental circumstances ; but cases have occurred which 
prove the possibility and actual occurrence of impermeable stric- 
tures. I admit, that the plates of Sir Charles Bell are overdrawn, 
but the case mentioned by Chopart f is conclusive, and accords 
perfectly with the dissection made by M. Delmas on a subject 
named Juniot, who died at the Hotel Dieu, from an extensive in- 
filtration of urine.J On this subject, the reader may likewise con- 
sult the case reported by M. Monod, and referred to by Cruveilhier 
in his great work, and which is also noticed in the Annates de 
Ohirurgie, 1842. I believe, that the obliteration did not take place 
until a fistula was established, through which the stream of urine 
was diverted. 

[Mr. Liston once boasted that he had never been foiled in intro- 
ducing a catheter with one hand, and it was not until some two or 
three years before his death that he encountered a case at the 
North London Hospital, which baffled him, and caused " the cold 
sweat to start in big drops from his forehead," (vide Lizars, on 
Strictures of the Urethra, pp. 18, 19.) Mr. ¥m. Cadge, the pupil 
and friend of Mr. L., informs us in the Lond. Med. Times, Nov. 
9th, 1850, that this distinguished surgeon, in the latter years of 
his life, abandoned his former opinion, that there are really no 
impermeable strictures. Mr. Syme, as is well known, still adheres 
to this opinion. In the very excellent Memoir on the Treatment of 
Stricture of the Urethra, &c, by Prof. Eve, of Nashville, {Nashville 
Journal of Medicine and Surgery, June 1853, p. 332,) this able sur- 
geon has reported a case in which, with all his well-known skill, 
he could not pass the stricture. After making an incision into 
the perineum, he '• drilled a hole through a hard cartilaginous 
mass occupying the membranous portion of the urethra." In a 
note, Prof. E. refers to another case, treated by Dr ; Webb, of S.i 

* Nos. Chirurg. torn. iii. p. 470. 

\ Traite des Maladies des voies urinaires, torn. ii. p. 323. 

j These inaugurate, of M. Selles, 1824. Also Soemmering, p. 174. 



STKICTURE. 101 

Louis. In this instance, Dr. "W., after opening the perineum, 
could not find the urethra ; he then cut out a cartilaginous mass 
an inch in length, around which he supposed the urine must have 
passed. Prof. Eve, in view of the above facts, very pertinently 
asks, " would not this have proved an impermeable stricture, even 
to Mr. Syme, of Edinburgh," and, we would add, to M. Amussat 
himself? Impermeable strictures are distinctly recognized in the 
Treatises on the Urinary Organs, both of M. Civiale and Prof. Gross. 

— g. c. b.] 

Structure. — A knowledge of the structure of a stricture is abso- 
lutely essential to a just appreciation of the means proposed for its 
treatment. Laennec, in his lectures, speaks of bridles formed of 
plastic lymph deposited upon the lining membrane of the urethra. 
The existence of this kind of stricture is denied on the grounds, 
1st, of the slight tendency of mucous membranes to form plastic 
lymph ; 2, the impossibility of the condensation of this lymph, 
owing to the frequent passage of the urine, by which it must ne- 
cessarily be removed. But one well-authenticated case is sufficient 
to destroy the force of these objections. Admit that the mucous 
membranes do not often secrete this lymph, still instances have 
occurred both in the intestinal canal and the laryngeal and 
bronchial tubes. Urine is not constantly passing through the 
urethra ; the interval of the acts is sometimes sufficiently long, to 
permit the condensation of a layer of plastic lymph, which process 
is often very rapid. 

Laennec deposited in the Museum of the Faculte de Medecine, 
a pathological specimen, in proof of his opinion : this I have not 
been able to procure. Besides, the preparation is now so old that 
one could not decide whether the stricture in this case was formed 
by a deposit of plastic lymph, or a thickening of the mucous mem- 
brane itself. The views of Laennec were admitted by Ducamp, 
and similar opinions were entertained by Morgagni, Sharp, 
Goulard, and other surgeons ; but further investigations on this 
question are to be desired. 

[This question has been definitely settled by the researches of 
that able surgeon, Mr. Hancock, of the Charing Cross Hospital, 
London. His recently-published work, " On the Anat. and Phys. 
of the Male Urethra, and the Pathology of Strictures of that Canal,'''' 
contains more valuable practical information than we have ever 
seen embodied in so small a compass. We shall have occasion to 
refer to this work again in noticing the subject of spasmodic stric- 
ture. In speaking of the influence of adventitious membranes in 
the production of stricture, (p. 74,) he remarks, that he is con- 
vinced that the latter depends upon the former more frequently 
than is commonly supposed : " To gain as much information as 
possible upon this point, I have examined all the urethras I could 
get. I have examined the urethras of those who have died of other 
diseases, in whom the existence of stricture had not been sus- 
pected; I have also, through the kindness of my friends, been 
enabled to examine preparations " taken from those who had at 
one time suffered from this malady, and who were supposed to 



102 VIDAL OX VENEREAL DISEASES. 

have been cured ; I have also been enabled to examine those 
taken from patients who have died whilst laboring nnder the 
complaint. And the result of these examinations is the convic- 
tion that permanent stricture from false membrane within the 
canal upon its free surface, is a common and frequent occurrence : 
and I am confirmed in this view by my friend Dr. Berth, who has 
rendered me great assistance, and who from his position at Green- 
wich Hospital, has had ample opportunity of studying these dis- 
eases, to which he has devoted much attention." At pages 75-78, 
Mr. Hancock has detailed some of the autopsies which he has 
made, and which prove incontestably the accuracy of his opinion. 

—a c. b.] 

In the majority of cases, the mucous membrane seems the only 
part affected ; its redness, consistence, and thickness are increased, 
and its elasticity impaired. When, at an autopsy, this lesion only 
is observed, we are surprised that it could have caused so serious 
an obstruction to the passage of the urine ; but we forget the con- 
gested state of the subjacent tissues which subsides after death, nor 
do we take into consideration the fact that this obstacle may have 
been increased by spasm. This is the most common form of stric- 
ture ; that through which, it may be remarked, the largest bougies 
are most readily passed. It should be remembered that the tissues 
subjacent to the mucous membrane are increased in thickness only 
by the temporary presence of a large quantity of blood, which is 
only temporary, being withdrawn at death, or which may be ex- 
pelled by well-managed external compression. Occasionally the 
mucous membrane is sound, and the subjacent tissues are alone 
affected. This does not imply that the former has not been dis- 
eased ; for it is to be supposed that it was primarily affected, the 
effects having here subsided, as in the case of certain alterations 
in the pyloric and cardiac orifices of the stomach, when these parts 
suffer from organic lesions. In proportion as the inflammation 
assumes the chronic form it becomes more profound, and the 
mucous membrane regains its natural aspect, whilst the subjacent 
tissues, especially the cellular, becomes indurated and hypertro- 
phiecl. 

Samuel Cooper was wrong in asserting, that when the mucous 
membrane is the seat of stricture, its color is whiter than natural : 
for the contrary is often the case, especially during the earlier 
stages of the disease. In my opinion, sufficient attention has not 
been paid to the morbid alterations in the tissues subjacent to the 
urethral mucous membrane. On this subject I beg the reader's 
indulgence, for its investigation may lead to important modifica- 
tions in the preventive treatment of strictures. The hypertrophy 
of the subjacent tissues is a fact well established, but it is produced 
in various ways: sometimes, it would seem that a deposit of 
plastic lymph had taken place in all the tissues of the part ; whilst, 
in other cases, these parts seem to be thickened only. These are 
the strictures to which the term fibrous has been applied. Cru- 
veilhier believed that they are all of this nature. On this point 
the reader may consult the Annates de Chirurgie, t. iv. p. 129. 



STRICTURE. 103 

However this may be, there is a projection into the canal as well 
as externally ; by pressing the urethra a decided induration may 
be felt. This variety of stricture is ordinarily of considerable 
length, and is most commonly found at the spongy portion of the 
urethra. To this category belongs the case reported by M. Lalle- 
mand, in which he speaks of a stricture of considerable extent, 
produced by the lesion of the walls of the urethra, and even of the 
tissues of the corpus cavernosum. After the death of the patient, 
on exposing the canal longitudinally, the indurated tissues pre- 
sented the aspect of a gun barrel split in its longest direction. A 
cartilaginous hardness has been spoken of in these cases. Some- 
times the length of these strictures is not considerable ; they then 
form a band which surrounds the urethra, protruding both within 
and without the canal. There are good grounds for believing that 
this kind of stricture is frequently the result of an abuse of cauter- 
ization. 

Nodosities form in the . substance of the cavernous bodies, and 
diminish the calibre of the urethral canal, though the latter may 
not be directly affected ; sometimes they do not in the least en- 
croach upon the urethra, but project externally."* 

Instead of becoming dilated and thickened, the cells of the sub- 
mucous tissues may contract and even become effaced. We then 
have, necessarily, a diminution of the calibre of the canal, and the 
formation of a contracted circular stricture as if caused by a liga- 
ture ; this is the variety to which, in my opinion, the term stric- 
ture atrophy should be applied. It is met with most frequently at 
the bend of the urethra. It should be borne in mind, that inflam- 
mation, after having invaded the tissues, does not always leave 
them in the same condition ; not unfrequently these tissues seem 
to enjoy a new vigor and activity ; but the contrary may happen, 
and hence the atrophy, and the development of that form of 
stricture to which we have referred. It is not, besides, the only 
instance in pathology where opposite effects are due to the same 
cause. 

We must likewise take into consideration the effect of the ab- 
scesses in the sub-mucous tissues which occur, either during or 
after a severe attack of blennorrhagia. Since my connection 
with the Hopital du Midi, I have found these very common in 
young girls. Now when these abscesses heal, a bridle or depres- 
sion remains. 

Ulcerations of the urethra which were once regarded as the sole 
cause of strictures, have since been denied a place in their etiology. 
But modern researches have shown that they are only less frequent 
than was formerly supposed, their existence having been clearly 
established. M. de Selles observes in the Thesis ahead}' quoted, 
that Dupuytren during his lectures, exhibited several examples of 
urethral ulcerations. Some of these were superficial, others deep 
seated, and appeared as if cut out with a punch. They were 

* Roche, Sanson and Lenoir, Nouv. elem. de Path Mcdico-Chirurgicalc, 4th ed. 
torn. iv. p. 596. 



104 YIDAL ON VENEREAL DISEASES. 

generally confined to a single point of the canal, in some instances, 
however, they occnpied its whole circumference. Around and 
beneath these ulcerations, the mucous membrane was engorged and 
thickened. These characters were particularly noticed in the cases 
mentioned in a note which I have received from my freind Dr. 
Groyraud, of Aix. 

It is obvious that the cicatrization of these ulcers must diminish 
the natural calibre of the canal, and the bridles formed resemble the 
cicatrices of burns. To this category belongs the stricture produced 
by cauterization either with caustics in a solid or diluted state. 

Yegetations, which by the ancients were called carnosities, are 
by no means so common as they supposed, a fact first established 
by the investigations of Brunner and Mery, and afterwards by 
those of Benevoli, Marini, Garengeot, Morgagni, Lafaye, Desault, 
and the more careful observations of modern surgeons. But Gir- 
tanner was wrong in asserting that these carnosities have but an 
imaginary existence, for they were observed by Morgagni, 
Hunter, Ch. Bell, Dupuytren, and Baillie. I myself have met 
with them, and M. Mercier has reported a remarkable case. I 
have twice seen them on the cadaver ; they are generally seated 
near the fossa navicularis. Wigelin and Lobstein have observed 
them behind the verumontanum. These, in my opinion, were cases 
of hypertrophy of the prostate or tumors of this gland. On this sub- 
ject Soemmering remarks : " The carnosities which I have observed 
in the lacunce were of a violet color, hard, of the size and form of 
a lentil ; they adhered by a kind of pedicle to the urethral mucous 
membrane ; it is an easy matter to ligate or excise them when they 
are not of too large size."* It is evident that Soemmering here 
refers to vegetations in the vicinity of the meatus. " But," he 
adds, " since these vegetations have been found to exist at both 
extremities of the urethra, why may they not occur at its middle 
portion?" He, however, never met with an instance of the kind : 
though the testimony of John Hunter, Benjamin Bell, Andre, and 
especially of Baillie, is sufficient to establish the fact of their ex- 
istence. More recently, together with M. Mercier, I have seen 
small vegetations along the whole course of the male urethra. I 
have also met with an instance where the urethra was rough 
throughout ; it was that of a prostitute, who was under my care at 
the Hopital du Midi These vegetations were of a whitish color, 
soft, and bled from the most trifling cause. With the aid of a 
catheter, and a finger introduced into the vagina, I detected their 
existence throughout the urethra. This girl was of a decidedly 
lymphatic temperament, and had no other symptoms of syphilitic 
disease; these vegetations were reproduced with a wonderful facility. 
Those situated most externally, I attacked with narrow-bladed 
scissors ; the others were cauterized with the nitrate of silver, which 
was introduced to a great depth. Yan Swieten refers in his Com- 
mentariesf to vegetations developed at the orifice of the urethra ; 

* Traite des maladies de la vessie et de Vuretre. Translated by M. Hollard, p. 167. 
f Vol. v,, p. 453. 



STRICTURE. 105 

these are not uncommon. It would appear that cancerous vegeta- 
tions may exist in the urethra. M. Lallemand has reported an 
example. But such an occurrence is exceedingly rare in the fe- 
male, especially as a primary accident. Cancer of the uterus may 
extend so as to invade the vagina and even the urinary appa- 
ratus. 

Nature. — The remarks which we have made upon the causes and 
pathological anatomy of stricture render any extensive observations 
upon their nature unnecessary. Thus, in the etiology, particular 
notice was given to wounds and inflammations. Both of these 
causes frequently lead to the same final result, viz. the fibrous 
condition of the parts. Thus, the cicatrix of a wound, and the 
condensation of the sub-mucous tissue arising from a protracted 
urethritis, produce the same anatomical changes, the fibrous or true 
stricture. As already stated, the inflammatory stricture is but the 
commencement of the fibrous, and it may also exist as a compli- 
cation of the latter variety. 

Is there a spasmodic stricture ? There is nothing in the struc- 
ture of the urethra, abounding as it does in erectile tissue, and 
surrounded as it is by muscular fibres, to forbid such an existence. 
Wilson's muscle alone may produce a constriction of the com- 
mencement of the membranous portion of the urethra. Spas- 
modic stricture, however, rarely exists alone, it is generally but a 
complication. In some cases, stricture would appear to be, at the 
same time, spasmodic, inflammatory, and organic. Suppose, for 
example, a chronic condensation at some point of the walls of the 
urethra, at which its natural calibre is diminished ; yet, the blad- 
der retaining its contractile power, the urine is freely evacuated. 
Now, let the subject of this stricture indulge in excesses, either at 
the table or venery, the obstacle to the passage of urine is soon 
increased ; its strain, which before was scarcely distorted, is now 
arrested ; but a bath, and the abstraction of blood, suffices to re- 
lieve the patient. It is evident, that the difficulty in this case 
arises from inflammatory congestion, and not from any permanent 
alteration in structure. The same patient is greatly excited by 
some accident ; he has retention of urine at once ; but it soon 
disappears, after some trifling remedy, or after his mind is restored 
to its accustomed tranquillity. We find, therefore, in the same 
subject, three kinds of stricture; at least, such is the case with 
those who admit this number, but it is obvious that but two of 
these are permanent, the spasmodic being but a complication of 
the other varieties. For the anatomical grounds on which this 
opinion is based, the reader may consult the well-written article 
of M. G-osselin, in the Archives de Medecine et Annates de la Clrir- 
urgie. 

[The muscularity of the urethra, a doctrine advocated by John 
Hunter, Sir Everard Home, Bauer, Wilson, Howship and Samuel 
Cooper, is, at length, positively established by the more modern 
researches of Messrs. Quekett and Hancock, of London,* and Kol- 

* Op. cit. 



106 VIDAL OX VEXEREAL DISEASES. 

liter, of Wtirtzburgh.* But, it is to Mr. Hancock that we are 
especially indebted for pointing out the practical bearings of the 
results of these investigations. It is now clearly demonstrated, 
that, as the urethra is muscular throughout its whole extent, spas- 
modic contractions may occur, independently, in any part of the 
canal, as well within an inch of the orifice of the urethra as at its 
membranous portion. Indeed, it was a case of the former, Mr. 
H. observes, that first led him to examine the minute structure of 
the parts microscopically. We cannot too strongly recommend 
the work of the latter gentleman, to those desirous of becoming 
acquainted with the true pathology of strictures. — Gr. C. B.] 

Symptoms. — The stream of urine is diminished in size, length, 
and force ; its course is altered, particularly in cases of lateral 
stricture ; its form is flattened like the blade of a penknife, or 
spiral and twisted like a gimlet, frequently it is bifurcated, or 
forked, to use the language of Ambrose Pare ;f in some cases, one 
of these forked streams projects beyond the rest, which fall upon 
the patient's feet, or are scattered in all directions ; in these cases, 
it appears as if they issued from four or five small orifices in the 
glans, which seem as if perforated like the spout of a water-pot. 
General^, in the normal state, the jet gradually diminishes in 
proportion as the bladder becomes emptied, and the curve which 
it describes is effaced, but in the case of stricture, this curve is, as 
it were, broken, and the stream is suddenly arrested. The blad- 
der is not completely evacuated ; the desire to urinate is soon 
again urgent and irresistible ; however, a long time is required to 
empty even a portion of the contents of the bladder. It may be 
stated, that the patient urinates longer and more frequently than 
natural, and yet the bladder is never empty. A certain quantity 
remains behind the stricture, which oozes in drops immediately 
after the patient has finished, as he supposes, the act. Mental 
emotions, and changes of temperature, modify the extent of the 
resistance opposed to the passage of the urine. The retention of 
the urine in the bladder leads to an alteration in its composition. 
It becomes more ammoniacal, less aqueous ; turbid, and sometimes 
a grayish deposit takes place ; it may be mixed with blood, pus, 
semen, and a glairy tenacious mucus, which, according to Sir 
Everard Home, indicates a lesion of the prostate gland. The 
emission of semen is obstructed, as well as of the urine. The 
slightest stricture interferes with its discharge, and it escapes after 
the erection has subsided. Sometimes the semen, instead of reach- 
ing the glans, takes a retrograde course towards the bladder. In- 
stead of a retention, we may have an incontinence of semen. 
Nocturnal pollutions are common in patients affected with stric- 
tures. The semen escapes, also, during a semi-erection, or during 
the act of defecation, without the consciousness of the patient ; 
but sometimes he experiences severe pain after an emission, as if 
a needle were thrust into the perineum. This occurs particularly 

* IfikrosJcopische Anatomie, &c. 

f (Euvres Completes. Paris, 1840. Vol. ii., p. 565. 



STRICTURE. 107 

where tlie stricture is seated in the prostatic portion of the urethra. 
M. Dezemeris was present at the autopsy of a young man who 
had suffered from repeated nocturnal pollutions ; in this case, ul- 
cerations existed at the orifices of the seminal ducts. 

Besides the urine and sperm, the urethra gives exit to the liquor 
prostaticus. This fluid is sometimes secreted in abundance, par- 
ticularly where the gland is irritated by the presence of a stricture 
in its vicinity ; but its emission is prevented only by very exten- 
sive stricture ; then it is carried away with the urine, or falls back 
into the bladder. With a stricture, there almost always exists a 
gleety discharge, more or less copious. This discharge generally 
proceeds from a point of the urethra, immediately behind the 
stricture, and is observed more especially in the morning. In 
some instances ; instead of being muco-purulent, this fluid is of a 
serous character, and is more or less limpid. When the stricture 
is of great extent, this matter, like the semen, is carried into the 
bladder, to pass off only with the urine ; in the latter we now find 
a deposit. When the stricture is of long standing, and when 
there is reason to believe that it is extensive, if we do not find 
this discharge from the meatus, we may suspect that it escapes 
from the other extremity of the urethra, or has accumulated in a 
pouch formed behind the obstruction. The lining membrane of 
the pouch in these cases assumes a villous aspect, and is preter- 
naturally reddened and thickened ; for it is constantly irritated, 
either by this prostatic fluid, or by the urine, which no longer re- 
mains in its natural reservoir. 

[In patients disposed to the formation of calcareous matter, the 
latter is apt to accumulate in the pouches or dilatations which form 
behind the seat of obstruction. A few years since, we removed a 
large stone from the membranous portion of the urethra, the ob- 
stacle to the passage of urine in this case having been caused by 
a congenital narrowing of the meatus, which, indeed, was nearly 
obliterated.— a. C. B.] 

Whatever may be the seat of the stricture, whenever pain is 
felt it is generally in the vicinity of the meatus ; however, when 
this pain is sympathetic, it indicates some lesion near the neck of 
the bladder. It is then also felt in the perineum, about the anus 
and rectum, or there is a more or less uncomfortable sensation of 
weight in these regions, especially when the prostate gland is 
affected. If the stricture be seated in front of the bulb, pain is felt 
along the scrotum and penis ; the projection formed by the obstruc- 
tion may be readily felt, particularly when it is caused by indurated 
nuclei in the cellular tissue of the urethra, corpus spongiosum, or 
corpora cavernosa. These pains extend towards the testicles and 
the hypogastric region, following the course of the ureters and the 
vasa deferentia, whence they are reflected to the glands from which 
they started. 

The efforts made by the patient to expel the urine affect the 
intestinal canal; faeces are passed involuntarily ; the inner coat of the 
rectum becomes prolapsed ; the small intestines, with certain other 
abdominal viscera, are displaced, and at length we find disorder 



108 VIDAL ON VENEREAL DISEASES. 

of the organs of circulation. Fever is established, and this is often 
of an intermittent type. This arises from the more or less exten- 
sive irritation of the urinary organs, but more especially from the 
greater or less absorption of urine, which occurs whenever its 
evacuation is prevented, or it may occur from an inflammation of 
the veins surrounding the neck of the bladder. 

Innervation is often seriously modified by the existence of a 
stricture, particularly when it is of long standing. The patient 
becomes exceedingly irascible, is constantly exaggerating his dan- 
gers, and not unfrequently becomes a complete hypochondriac. 

Nothing can exceed the sufferings which the patient, in some of 
the graver forms of stricture, experiences. There is strangury and 
complete retention of urine. Desperate efforts are made to void 
the urine, he becomes agitated and is seized with despair ; his face 
is flushed ; his eyes protrude ; he cries aloud for aid ; he seizes a 
chair or a table ; stamps his feet ; he squats, for he is in constant 
apprehension that the faeces will escape, and escape they do. At 
this crisis hernia may form, hemoptysis occur, or pulmonary em- 
physema be produced. The spectacle is heartrending ; but unut- 
terable is the joy of the patient at the moment of his deliverance. 
His gratitude is expressed in glowing terms. 

Diagnosis. — This is not always easy, though of the highest im- 
portance in a practical point of view. Notwithstanding the numer- 
ous researches that have been made, and the ingenious methods 
devised for the purpose, the diagnosis is sometimes difficult. Occa- 
sionally, as already stated, a stricture exists and the patient remains 
ignorant of the fact, in consequence of the little suffering to which 
it gives rise. (Desault, Lallemand). When the stricture is seated 
beyond the bulb no tumor can be felt along the urethra; the 
stream of urine is not materially altered ; and the patient's attention 
is directed solely to the constant gleety discharge. In some 
instances this discharge ceases for a time, and it is only long after- 
wards, when age has enfeebled the bladder, or when the stricture 
itself has become more extensive, that the jet of urine is so modified 
as to leave no doubts as to the existence of an obstruction in the 
urethra. But a retention of urine may arise from other causes ; as 
for example, a foreign body without, or within the bladder, an 
enlarged prostate, a tumor in the vicinity, &c, &c. It is easy to 
distinguish these tumors from true stricture. An enlarged prostate 
may have nearly the same antecedents as a stricture, but the former 
most generally occurs in persons upwards of fifty years of age, and 
is not often accompanied with a discharge, whilst the latter is 
seldom absent in stricture. Again, in the case of an enlarged 
prostate, with the aid of a finger passed into the rectum, even a 
large catheter may almost always be introduced, and the enlarge- 
ment of the gland be thus detected. In the case of stricture some 
resistance is felt at first, then a gentle shock against the instrument 
indicates that an obstacle has been encountered. But we must be 
careful not to confound the kind of valve near the bulb with a true 
stricture, for it frequently gives rise to the same sensation as the 
latter. There are several other points in the urethra at which an 



STRICTURE. 109 

instrument may be arrested, unless great care be taken to follow 
the natural axis of the canal, but by withdrawing the instrument 
a little, depressing its handle gently, and delicate manipulations of 
this kind, the obstacle, depending upon this cause, may generally 
be surmounted. Wax bougies are almost exclusively used by M. 
Civiale, both for the purpose of obtaining an impression of the 
form of a stricture, and as an agent of dilatation. Should the 
stricture be complicated with inflammation, this instrument may 
be firmly held at some point of the urethra anterior to the stricture, 
and during its detention become so softened and distorted as to 
render it useless for the objects intended. Ducamp was also accus 
tomed, before proceeding to cauterization, to introduce a wax 
bougie, peculiarly modified, for the same purpose, and he boasted 
that, from the knowledge thus obtained, of the form, extent, and 
other conditions of the stricture, he could treat it with the same 
precision as if it were fully exposed to view. Sir Charles Bell 
proposed the use of metallic bougies, with a bulbous extremity, 
but their inflexible nature rendered their introduction sometimes 
painful. M. Leroy d'Etiolles, to remove this objection to their 
use, recommended that they should be made of gum elastic. These 
bougies have an olive-shaped extremity, more or less elongated, 
by which their introduction, in some cases, is much facilitated. 

[Profs. Syme and Gross attach but little value to the impress- 
ions obtained by the wax bougies. The former denounces it as 
a " preposterous" procedure, and says that it can result only in 
the deception either of the practitioner or patient. Mr. Guthrie 
considers that, for examining the urethra, a conical solid silver 
sound is the best instrument {op. cit. p. 69). It should be of a 
size, he observes, not more than two-thirds of that of the meatus. 
Mr. Miller {Practical Surgery, p. 522,) states that a metallic instru- 
ment is quite capable of fulfilling all ordinary indications in this 
way. Sir Benjamin Brodie asserts that the best instrument for 
diagnosis is the plaster bougie " of full size, and large enough to 
fill the urethra" {op. cit, p. 23). He objects to the use of conical 
bougies, which he thinks are liable to extend forcibly the orifice 
of the urethra, and to excite inflammation. Prof. Gross recom- 
mends a common silver catheter, of moderate size, and a little coni- 
cal at its extremity. Almost every surgeon has his peculiar mode 
of exploring the seat of a stricture, and doubtless, in Ms hands, it 
is the best. No matter what the method adopted, in some cases 
an accurate diagnosis is impossible. — G. C. B.] 

Treatment — We must never lose sight of the fact, that inflamma- 
tion is not only the most common cause, but may be one of the 
complications of stricture. This knowledge will lead us to be gen- 
tle in our manipulations, and to resort at once to the use of anti- 
phlogistics, whenever the latter may be indicated. In some 
instances, they may obviate the necessity of resorting to the 
operations commonly employed in the treatment of strictures, all 
of which may be comprised under the heads of dilatation, cauteri- 
zation, and incision. 

Dilatation. — This is generally attempted by means of bougies. 



HO TIDAL ON VENEREAL DISEASES. 

The time during which they are permitted to remain, varies with 
different practitioners. Thus, until recently, this period varied 
from two to fifteen hours. The interval of their use also differs. 
With some, this may be three days, with others they are used 
every day. With MM. Civiale and Pasquier, I prefer to leave 
them in the urethra not longer than five minutes, and to prolong 
the sitting at the same time, gradually increasing the size of the 
instrument. This may be called temporary, gradual dilatation. 
But more recently, mention has been made, on the authority of 
M. Lallemand,* of a rapid dilatation. M. Pirondi, who has ably 
described and advocated this method, has not been guilty of the 
exaggerations of M. A. T. Chretien, f who proposes sudden, forced 
dilatation. The enormities of M. Mayer, in my opinion, can find 
but few imitators. His principle, that the narrower the orifice of the 
stricture, the larger should be the instrument employed, must disgust 
every sensible mind. His bougies consist of six in number, vary- 
ing from two to four and a half lines in diameter. When the 
instrument has reached the seat of stricture, he hesitates not to 
press with force : various movements are given to the instrument, 
as from left to right, from before backwards, and in a spiral 
direction. 

[For all the objections to this method, we must refer the reader 
to our author's Traite de Pathologie Externe, &c, 3d ed., vol. V., 
pp. Ill, 116.— a. C. B.] 

My treatment is based upon the following principles : gradual 
and gentle dilatation, at first with conical wax bougies, like those 
so successfully employed by M. Civiale ; in recent cases, and 
where the stricture is not of a fibrous character, I rest satisfied 
with these means. Afterwards, I may substitute for the wax, 
gum elastic bougies, but in all cases they are used gently, and 
suffered to remain but for a short time in the urethra. 

[Prof. Gross states that he is satisfied from ample experience 
that the very best instrument for dilating a stricture is the com- 
mon silver catheter, with a slightly conical point. " I have em- 
ployed this instrument now in the treatment of this affection for 
upwards of twenty years, and nothing could induce me to abandon 
it. It possesses all the requisites that such an instrument ought 
to have, viz., lightness, firmness, and durability, and is incompar- 
ably superior, in every respect, to all the metallic, wax, gum-elas- 
tic, ivory, and other bougies, that have ever been invented. . . . 
My desire is merely to recommend, in strong and decided terms, 
an instrument which is capable, as a general rule, of fulfilling 
every indication presented in this disease, even in its worst forms, 
and which, I am satisfied, is much less appreciated than it deserves 
to be." Mr. Fergusson gives the preference to the bougie, and 
generally employs the plated steel rod, or a silver tube. Mr. Syme 
asserts that the best instruments for dilatation are made hollow, 
of Berlin silver, which possesses the requisite degree of rigidity, 

* Gazette Medicate, 1835. 

\ Bulletin Therapeutiquc, torn. xvi. p. 288. 



STRICTURE. 



Ill 



4. 



W 



takes a fine polish, and is not liable to rust. {On Strictures of the 
Urethra, p. 44.) Sir Benjamin Brodie {op. cit. p. 33,) uses the 
common plaster bougie, as well as those 
made of solid silver. He likewise, in Fl ^ s ' 1 ' 
some cases, employs the gum catheter, 
which he allows to remain day and night. 
This induces suppuration in the urethra, 
after which a large-sized instrument may 
be introduced. The wax bougie is liable 
to bend upon itself, as represented in Fig. 
1st. Fig. 2d, Porte Empreinte, an ex- 
ploring instrument. Figs. 3 and 4, coni- 
cal and fusiform bougies. — Gr. C. B.] 

I have already stated, that an instanta- 
neous dilatation has been highly extolled, 
and it is proposed to banish the practice 
of permitting sounds or bougies to remain 
in the canal * MM. Civiale, Leroy, A. 
Pasquier, approve of this method, with- 
out, however, excluding others. For example, M. 
Civiale permits the bougie to remain from two to 
three minutes to half an hour ; whilst M. Pasquier 
never allows it to remain more than five minutes. 
It is evident, that certain strictures may be re- 
moved by the employment of a certain number 
of bougies, gradually increasing in size, which are 
introduced and withdrawn one after another, or 
which may be permitted to remain for five or six 
minutes ; but, in my opinion, certain fibrous stric- 
tures can never be cured in this manner, believing, 
as I do, that the dilating agent must be allowed to 
remain for a longer period in the urethra. 

[Mr. Thomas Wakeley, of the Eoyal Free Hospi- 
tal, and Mr. Bernard Holt, of the Westminster 
Hospital, London, within the last<three years, have 
published numerous cases in the London Lancet, 
illustrating the efficacy of certain instruments in 
the treatment of stricture, which they have devised 
and employed, and the object of which, like the 
method of M. Benique, is, in the language of Hun- 
ter, to act "like a wedge upon inanimate matter." 
Indeed, more than thirty years ago, Mr. Guthrie 
had a dilating instrument made by Mr. Weiss, for 
this purpose. At first, this consisted of three blades, 
which were gradually separated by the action of a 
screw which turned in the handle, but the same 
mechanism was afterwards applied to a two-bladed instrument. 
{Guthrie on Urinary Organs, Am. Ed. 181*5, p. 76.) At page 77, 
he observes : "I thought I had now obtained an instrument which 



* Vide the last article of M. Benique. 



112 VIDAL ON VENEREAL DISEASES. 

could not fail of fulfilling all my expectations, and was only disap- 
pointed by finding that it did too much. The opportunity of dilating 
was in general too tempting to be resisted, and the consequence was, 
that it produced irritation in so many cases, that I was forced to 
give it up, having also fully satisfied myself that dilatation, to 
whatever extent it might be carried, could not cure the worst 
kinds of stricture." After noticing the dilating instrument of Mr. 
Arnott, consisting of softer materials, and which is dilated by means 
of air or water, he adds, p. 78 : "I do not now use instruments of 
this kind, either from their often failing, or being so troublesome, 
whilst they place the surgeon too much in the hands of the instru- 
ment maker, unless he has time and ingenuity to make them him- 
self, and they are after all unequal to effect a cure in the more ag- 
gravated cases of disease." At page 96, Mr. Gr. states that he gives 
the preference to a pliable hollow gum elastic bougie, of a medium 
size, perfectly smooth, and tolerably round at the point, so as to 
give as little uneasiness as possible. 

The method of M. Benique, to which our author has referred, 
is regarded by Messrs. Eicord and Acton as "pretty," but they 
observe that the idea emanated rather "from a mathematician than 
a practical man." (Acton, op. cit. p. 99.) However true the latter 
observation may be, as applied to M. Benique, this method has 
recently been most highly lauded by one of our own countrymen, 
who is both a mathematician and a practical man. We refer to the 
very able paper of Prof. Eve, to which we have already alluded." 
This paper concludes with the following propositions : 

1. " That while dilatation is the proper treatment for stricture 
of the urethra, this has hitherto failed to effect a cure, because in 
the ordinary mode of applying it, the seat of the disease has not been 
specially acted upon by the dilating instrument. 

2. "To cure stricture, the orifice of the urethra must be so en- 
larged that the canal beyond it may be dilated to its original size, 
which we ought to recollect is about twice that of the opening lead- 
ing to it. Instead, therefore, of being satisfied with introducing 
bougies of two lines in diameter through a restricted portion, they 
should measure four to five lines in thickness. 

3. "There is no necessity to confine a patient to bed in treating 
stricture ; once an instrument has been introduced, it has done all 
it can to expand the passage and should be withdrawn, that others 
larger in size may be immediately substituted. While this process 
ought to be cautiously and very gradually conducted ; still the 
more rapidly and freely it can be applied, provided no pain is 
excited, the sooner the disease will be removed. 

4. " By this method strictures may 'be permanently cured in a few 
days, without suffering, inconvenience or exposure, to serious conse- 
quences •." 

The box of M. Benique consists of thirty-six pewter bougies, in 
diameter from one and one-third to five lines, cylindrical, of the or- 
dinary curve, and flexible. From two or three to seven or eight 

* On Treatment of Stricture of the Urethra by rapid and free Dilatation, <£r., dtc. 



STRICTURE. 113 

may be introduced at each sitting, which, if no irritation be devel- 
oped, may be daily repeated. If necessary to pass the large size, 
the orifice of the urethra may be enlarged with the knife. 

The trials yet made with these instruments, are not sufficiently 
numerous, we fear, to justify the unqualified praise of Prof. Eve. 
He has been able to furnish but two cases from his own experi- 
ence, which he is compelled to admit are defective, especially in 
regard to time, and in one of these, certainly a desperate one, dila- 
tation was successful, only after the employment of the knife. 
Even after the external incision in the case, nineteen days were re- 
quired to pass a bougie measuring one-fourth of an inch in diameter. 
Prof. E. remarks, that when this patient returned home, so scep- 
tical were his friends as to the relief he had experienced, that they 
required ocular demonstration, " whereupon he, in true "Western 
hyperbolical language, offered to aid any water-wheel deficient in 
power, if they would only let him mount a fence I" 

Perhaps subsequent experiments, on a more extended scale, 
may prove that these instruments, as well as those recommended 
by Messrs. Wakeley and Holt, like the contrivances of Mr. 
Guthrie, are capable of " doing too much. 11 Mr. Wakeley 's expe- 
rience, thus far, however, has been highly encouraging. In the 
dilatation of the female urethra, the vulcanized India-rubber appara 
tus of Mr. R E. Hodges, may be used, for a description of which, 
together with those of Messrs. Wakeley and Holt, we would refer 
the reader to the excellent work of Mr. Fergusson on Practical 
Surgery (Am. Ed.\ where may also be found some judicious ob- 
servations upon the methods of treatment to which we have here 
alluded.— a C. B.] 

Cauterization. — Surgeons of the XVth, XYIth, and XVIIth cen- 
turies, among whom may be named A. Feri, A. Pare, Loyseau, 
and F. de Hilden, resorted to cauterization to remove urethral 
obstructions, which they supposed to be caused by vegetations, 
fungous growths, and carnosities within the canal. Hunter was 
the next whose name stands conspicuous in connection with this 
mode of treatment. In 1822, Ducamp (Traite des retentions d 1 urine) 
stamped upon it a character of certainty that caused it to take pre- 
cedence over all other methods in the treatment of stricture. There 
are two kinds of cauterization, the lateral, and the direct or antero- 
posterior. 

Lateral Cauterization. — This may be done with the porte-caustique 
of Ducamp, or of M. Lallemand. The modification of the latter 
instrument, however, as made by M. Segalas, by which the ad- 
vantages of Ducamp's and that of M. Lallemand are combined, is 
preferable to either. 

Anteroposterior Cauterization. — For this purpose, Ambrose Pare 
employed coated bougies; Hunter, a porte-caustique stylet, which 
was introduced through a canula; Everard Home, an armed 
bougie. M. Leroy d'Etiolles has brought the instrument of Hunter 
to perfection. It now consists of a gum-elastic tube, with a fixed 
curve, at the extremities of which are two ferrules, the external of 
silver, the vesical of platina. An obturator closes the orifice of 

8 



114 VIDAL OX VENEREAL DISEASES. 

the tube, while it is passed towards the seat of stricture. As soon 
as this is felt the obturator is withdrawn, and a rod substituted, 
of which the vesical end is charged with caustic, the latter, nitrate 
of silver, being contained in a platina cup. Instead of the nitrate 
of silver, we may use the Vienna paste. The urethra should be 
cleansed of all mucosities before the caustic is applied. 

One word in reference to the comparative advantages of dilata- 
tion and cauterization. The advantages and inconveniences of 
both have been mutually exaggerated by their respective advocates. 
Thus, it has been urged, that by dilating a stricture we do not 
destroy it, on which account it is of course liable to return. Cau- 
terization, carried to a certain point, does, indeed, effect its destruc- 
tion ; but it cannot insure us against a relapse, and, in the opinion 
of some surgeons, this will assume a graver form, an modular 
cicatrix is in fact produced, endowed with considerable retractile 
power, which property may aggravate the condition of the patient. 
The application of caustic requires extreme accuracy in the diag- 
nosis of stricture, both as to number, seat, extent, direction, &c. 
Now this is impossible in practice, therefore with caustic we must 
always operate in the dark, as is the case in the operations of 
incision and scarification, to which we shall soon refer. The 
caustic or point of the cutting instrument may be thrust into 
sound parts, by which, instead of benefiting we injure the patient. 
M. Lallemand and his disciples rely exclusively upon cauterization, 
rejecting dilatation altogether, a course which, in my opinion, is 
attended with serious objections. 

The question is different if by cauterization, it is proposed merely 
to modify the vital action of the parts. The slightest contact 
is then sufficient, and of course, this superficial cauterization must 
be free from the risk of that which is more profound, as must be 
frequently practised by M. Lallemand and his followers. There 
are cases, on the other hand, when the smallest sized bougie cannot 
be passed, though the patient may, after desperate efforts, succeed 
in voiding his urine. Again, there are case where neither a bougie 
nor the urine can pass, then direct, or the antero-posterior cauteri- 
zation may be followed with the happiest results ; for this purpose 
the instrument of M. Leroy is admirably adapted. 

[Prof. Gross notices an objection to the instrument of M. Lalle- 
mand, which is certainly of a serious character. He states that 
from the manner in which the cup is joined to the rod, it is liable 
to be broken; and he refers to the instance of a physician in 
Buffalo, who was in the habit of cauterizing himself with this 
instrument, and in which this accident proved fatal. (Treatise, p. 
642.) To obviate this risk, Prof. Gr. now employs the instrument 
represented in Fig. 5 ; which he says is all that can be desired. It 

Fig. 5. 




STRICTURE. 115 

resembles a common silver catheter, straight or curved, according 
to the situation of the stricture. At its vesical extremity is an 
eyelet three-quarters of an inch in length and two lines in width, 
corresponding with the cup containing caustic, which is attached 
to a rod. The cup is partially filled with tallow, soap, or extract 
of hyosciamus, and this is sprinkled with a thin layer of the pow- 
dered salt, a much better plan, he asserts, than that of melting 
the caustic over a lamp. 

" To this method and this instrument," he observes, "am I in- 
debted for two of the most perfect cures I ever effected. I should 
not be surprised if cauterization should again become a favorite 
mode of treatment." 

For a favorable notice of this method the reader may consult the 
Practical Observations on Strictures, &c, by Mr. Eobert Wade, (Lon- 
don, 1853, pp. 79, 181.) See, also, the Treatise of Prof. Gross.— GL 0. B.] 

Incision. — Resection. — A variety of sheath-bladed instruments 
have been recommended by MM. Kicord, Gruillon, Leroy, Amus- 
sat, Stafford, and others, for the internal division of strictures, but 
this method of treatment is liable to the same objections as that by 
cauterization. It must, however, be admitted, that in cases of 
valvular growths near the meatus, and in the prostatic portion of 
the urethra, it may be advantageously employed. Should com- 
plete retention of urine occur we must then resort to the button- 
hole incision, (boutonniere), or puncture of the bladder. 

[Sir Benjamin Brodie has given the particulars of a very bad 
case, (op. cit. p. 41,) in which he resorted to a modification of Mr. 
Stafford's operation. In this case, a plaster bougie having been 
passed down to the seat of the obstruction, an opening was made 
in the perineum. The bougie was then withdrawn and an instru- 
ment introduced in its place, which consisted of a straight silver 
tube, closed at its extremity, except a narrow slit, through which 
a small lancet could be made to project by pressing on a stilet 
which projected from the handle of the instrument. " The round 
extremities of the instrument being pressed against the anterior 
part of the stricture, the lancet was protruded and the stricture 
divided." The advantages of this proceeding, he adds, consists in 
the fact that the free opening in the perineum prevents all danger 
from infiltration of urine ; and the application of the finger to the 
posterior surface of the stricture serves as a guide for the lancet, 
by which we can make an exact division of the stricture. Mr. 
Gruthrie, referring to Mr. Stafford's instrument, (op. cit. p. 92,) says, 
" it must always be a two-edged tool, capable of doing much good 
and much mischief." We have often seen M. Civiale perform the 
internal division of stricture with the happiest effects, and if proper 
care be taken we are satisfied this operation will not often be pro- 
ductive of ill consequences. — Gr, C. B.J 

Button-hole Incision (Boutonniere). — A staff or catheter having 
been passed as far as the seat of stricture, is held by an assistant. 
The surgeon makes an incision along the raphe, and seeks for the 
membranous portion of the urethra ; by freely incising its inferior 
wall, he reaches the staff which the assistant withdraws a little. 



116 



VIDAL ON VENEREAL DISEASES. 




"Whilst searching for the continuation of the canal he directs the 
patient to urinate. A grooved staff or stilet is then introduced 
into the urethra, which serves as a guide in prolonging the incis- 
ion beyond the seat of stricture. „. n 
A catheter is then introduced, 
which is allowed to remain, and the 
edges of the wound are brought to- 
gether. 

[Mr. Fergusson says that he has 
been much pleased with the instru- 
ment represented in Fig. 6, in treat- 
ing slight strictures within an inch or 
two of the glans, or even deeper 
than an ordinary bistoury can reach. 
Figs. 7 and 8 is an ingenious instru- 
ment, manufactured by Tiemann, com- 
bining blades both for the lateral and 
antero-posterior incisions. Fig. 7 
represent for lateral incision, Fig. 8 
for antero-posterior. — Gr. C. B.] 

In my opinion, this operation is not 
justly appreciated. Its difficulties and 
dangers have been exaggerated, and 
I believe that it will become more 
general in proportion as surgeons be- 
come better acquainted with the anatomy of the parts, 
for then, if the staff fail to reach the point at which we 
propose to operate, we shall know where to find it. In 
such a case a knowledge of anatomy is our best guide. 
The stricture, in these cases, is almost always seated 
at the commencement of the membranous portion, and 
this is the point where the opening should be made ; 
now, it is not very difficult to find the bulb of the 
urethra, nor to follow the course of the raphe, as in 
the incision for lithotomy. Guided by anatomy alone, 
the surgeon cuts down upon an artery, — why should 
he not, in the same manner, cut for the membranous 
portion of the urethra, the position of which is far less 
liable to change than that of an artery ? If the mor- 
bid alterations of the part have produced such a change 
it is an advantage to the operator, for this alteration 
is a dilatation, which renders this part of the canal 
more easy to be found and opened. There can be no 
comparison between the dangers of this operation and 
that of forced catheterism, or puncture of the bladder. 
It is limited to the perineum, remote from the deeper 
fascia, and consequently from the peritoneum. Strictly 
speaking, it does not affect the pelvic cavity, but only 
its walls. This operation places the male urethra in a 
condition similar to that of the female : the catheter has but a short 
distance to pass to reach the bladder, and if the prostate gland be 



STRICTURE. 117 

not affected, this is readily accomplished. A staff, sound, or bougie, 
may also be passed through the stricture from behind forwards, 
to meet another introduced at the meatus. In the majority of 
cases, these instruments may be brought into contact, and may 
afford as valuable information as to the extent and the thickness 
of the stricture, as well as of other matters required to guide us in 
our treatment. 

[In 1849, Mr. Syme of Edinburgh, published a work on stric- 
tures of the urethra, &c, in which he attempts to prove (p. 58) 
that: 

1st. "The division of a stricture by external incision, is suffi- 
cient for the complete remedy of the disease, in its most inveterate 
and obstinate form. 

2d. " That, in cases of less obstinacy, but still requiring the 
frequent use of bougies, division is preferable to dilatation, as 
affording relief more speedily, permanently, and safely." 

Mr. Syme claims as the peculiarity of his operation, that instead 
of simply passing a staff, sound, or catheter down to the seat of 
stricture, a grooved staff is passed through the stricture before the 
incision is attempted, there being, in his opinion, no such thing as 
an impermeable stricture (p. 57). Of course, where this can be 
done, the operation must be greatly facilitated and rendered more 
free from danger. Thus performed, he states, it is "completely 
effectual." From the cases reported in the volume to which we 
have referred (p. 13), it would appear that Mr. Syme performed 
his first operation about the year 1838. Since that period, we 
believe that he has operated in upwards of sixty cases without a 
fatal result. He asserts that, if " correctly performed," the opera- 
tion is perfectly safe. Now, fatal cases have occurred to Messrs. 
Bransby Cooper, Cock, Gay, Coulson, Mackenzie, and Fergusson. 
These deaths occurred from phlebitis, hemorrhage, urinary infiltra- 
tion, &c, &c. In other instances, patients have had a very narrow 
escape. Now, we think that few will be disposed to attribute the 
fatal results which occurred in the practice of the above-named 
surgeons to their inability to perform the operation " correctly." 
There can be no question, that even in the most skilful hands, it 
is not devoid of danger. The suffering, which the patients have 
long endured, on whom this operation is performed as a dernier 
resort, doubtless increases its hazards. If surgeons would resort 
to it at an earlier period of the disease, instead of aggravating the 
condition of the patient, by fruitless efforts at dilatation, where 
dilatation is impossible, we believe that the operation would pre- 
vent much distress, and, in many cases, prepare the patient for a 
radical cure by the very means which were before ineffectual, 
Mr. Fergusson recommends that it should not be practised indis- 
criminately ; and as he speaks impartially, and from experience, 
we cordially commend the remarks on this subject in the last edi- 
tion of his Practical Surgery, to those who propose to perform the 
operation. Professor Mussey informs us that, in a case in which 
he not long since resorted to it, he was much pleased with the 
results. 



113 VIDAL ON VENEREAL DISEASES. 

In the text, our author has spoken of the simplicity and safety 
of the old operation — the button-hole incision, in cases of imper- 
meable stricture. Mr. Fergusson states, in his Practical Surgery, 
that he has had two fatal cases in his own practice from this pro- 
ceeding, and Sir Benjamin Brodie {On Urinary Organs, 2d Am. 
ed., p. 40), alluding to an operation performed by himself, which 
consisted in laying open the whole of the contracted portion of the 
urethra, speaks of the difficulties connected with these operations ; 
and the testimony of Professor Gross, who performed it some thir- 
teen years ago {op. cil\ is to the same effect. The operation to 
which we now refer for impermeable stricture, and which has been 
performed and recommended by Collot, Petit, Wiseman, Bertrandi, 
Arnott, Shaw, Desault, Hunter, Cooper, and others, seems to have 
been almost universally mistaken for that claimed by Professor 
Syme, the peculiarity of which, as already stated, consists in cut- 
ting clown upon a small grooved staff passed through the stricture. 
For a more complete account of the present state of the question, 
see Eeport of the proceedings of the Royal Medical and Chirurgi- 
cal Society, April, 1853, in the American Journal of the Medical 
Sciences, July, 1853, p. 226. M. Ricord, in noticing Mr. Syme's 
operation {Notes to Hunter, 2d ed., p. 259), merely states, that the 
cases reported would seem encouraging, but M. Civiale, as we were 
personally assured by him, never resorts to it ; the old operation, 
however, he informed us, he frequently performs. The Irish sur- 
geons are decidedly opposed to it. During our recent visit to 
Dublin, Mr. Porter, the president of the College of Surgeons, de- 
clared to us, that he would venture to assert that it never had been 
performed in that city, and that it never would be ! — Gr. C. B. 

[Urinary Abscesses. — Infiltration of Urine. — Under the head of 
blennorrhagia our author briefly referred to peri-urethral abscesses, 
which form during the existence of that disease. Among the con- 
sequences of stricture, we have likewise to note the development 
of abscesses, produced by the constant distention and irritation of 
the parts behind the seat of obstruction. In obstinate cases the 
continual straining of the patient is very likely to terminate in this 
manner. Ulceration may likewise ensue, and the urine be gradu- 
ally infiltrated into the adjacent loose cellular tissue. It forces its 
way slowly in some instances, in consequence of the adhesive 
inflammation which its presence excites ; in other cases, from a 
rupture of the urethra, a sudden and extensive infiltration may 
take place, which shall result in the sloughing of portions of the 
urethra, or the entire canal, together with the glans penis and 
scrotum. The peculiar arrangement of the perineal fasciae, causes 
the direction of the effused urine to vary according to its seat. 
Fig. 9 shows the tumefaction of the scrotum and perineum from 
infiltration of urine. If it occur in the membranous portion it 
passes under the sheath of the levator ani, laying bare the rectum ; 
if at the bulbous portion, it encroaches upon the deep-seated fascia 
of the perineum, and is arrested in its course opposite the anus, 
from which point it may extend so as to involve the circumference 
of the penis, the scrotum escaping entirely, (Malgaigne.) It may 



URETHRORRHAGIA. 119 

also reach, towards the groin and abdomen, infiltrating the cellular 
texture of all the coverings of these parts. Mr. Shaw, in his Notes 
to the work of Sir Charles Bell, on Diseases of the Urethra, (3d 
Lond. ed., p. 244,) has related an extraordinary example of the 
extent of the infiltration and suppuration which sometimes occurs. 
In this case there was sloughing not only of the coverings of the 
penis and scrotum, but of the loins and abdomen, as far as the um- 
bilicus, and in a downward direction as far as the knee, and yet 
this patient finally recovered ! At page 267, Sir Charles Bell has 
reported a case which proved fatal from delay ; the swelling was 
on the left side of the pubes, and was mistaken for a hernia. 
When the urine is effused into the corpus spongiosum, and limited 
to this body, the penis may assume a semi-erect appearance, as in 
the case described by Mr. Earle, in the Lond. Med. Gazette, vol. ix. 
p. 736. In the same journal, p. 213, he relates a case where the ure- 
thra gave way about an inch from the external orifice ; the under 
surface became enormously swollen, and a pouch or kind of second 
bladder was formed, which it was necessary to empty whenever 
the bladder was evacuated. It will be seen in Fig. 10, (from Sir 
Charles Bell,) that notwithstanding the numerous external fistulous 
openings, there is but one communicating directly with the urethra. 
Treatment. — When no communication exists between the abscess 
and the urethra it must be opened in the same manner as when 
seated near the rectum. If confined behind the deep-seated fascia 
the only indication of its existence may be a slight degree of ful- 
ness and deep-seated hardness in the perineum. The matter having 
been reached by the point of the bistoury, the opening may be 
enlarged by directing the instrument downwards and outwards, as 
in the operation for lithotomy. In many of these cases no time is 
to be lost ; a free exit must be given to the matter or the most 
serious consequences may follow. The fistulous openings result- 
ing from these abscesses, of course, can be cured only after the 
stricture has been removed. When extensive sloughing of the parts 
covering the urethra has taken place, and the granulating process 
is insufficient for their reparation, recourse must be had to plastic 
surgery, on which subject the works of Mr. Earle, Sir Astley 
Cooper, Delpech, Dieffenbach, and Messrs. Eicord and Jobert may 
be consulted. The latter surgeon in particular has devoted especial 
attention to these operations, and in his splendid volume on Plastic 
Surgery the practitioner may find every desirable information. — 
G. C. B .] 

URETHRORRHAGIA. 

Symptoms. — Nothing is more common than the discharge of 
a small quantity of blood by the urethra. It is not, strictly speak- 
ing, an accident, but only a symptom, which I have noticed under 
the head of urethritis. Sometimes, however, it happens that the 
quantity discharged is sufficient to constitute a true accident, a 
hemorrhage. Thus we occasionally find that the blood flows in a 
full stream, unmixed with urine or with a muco-purulent matter, 



120 VIDAL ON VENEREAL DISEASES. 

and without any effort to urinate on the part of the patient. This 
hemorrhage may last for an hour, and weaken the patient to a 
surprising extent. Generally the discharge is not so abundant, 
and it is rare that a glass of blood is lost. In every instance the 
patient experiences relief, or a temporary improvement after this 
discharge. Severe cases occur in paroxysms, which are sometimes 
excited by a walk, by imprudence, and occasionally occur without 
any evident cause, even while the patient remains in the horizontal 
position and is submitting to anti-hemorrhagic treatment. If the 
hemorrhage be considerable, and often repeated, the relief of which 
I have spoken, is followed by syncopes and a prostration of 
strength which scarcely permits the patient to raise his eyelid. 

Causes. — Attempts have been made to establish the etiology of 
urethrorrhagia, Among the causes assigned are severe inflamma- 
tion, wounds, rupture of certain vessels, a hemorrhagic diathesis, 
and finally, a change in the mode of action of the cause which 
ordinarily gives rise to blennorrhagia. I believe that the etiology 
of this affection may be regarded under all these aspects, and we 
should not be exclusive in our views. Thus it is evident, that in 
very severe cases of blennorrhagia, with the muco -purulent matter, 
mingled or separate, some drops of blood may be discharged which 
have oozed from the inflamed surfaces. There is a manifest solu- 
tion of continuity in the vessels in cases of rupture of the cord by 
a blow of the fist, by coitus or masturbation, which certain indi- 
viduals practice during a blennorrhagia even when most severe, 
either to gratify their passions or to cure the disease. In these cases 
the hemorrhage may be very abundant ; it is of a bright red color 
and jets like arterial blood. These are the instances in which the 
discharge is followed by so much relief; it also hastens the sub- 
sidence of the inflammatory symptoms ; but it is the harbinger of 
troublesome days to the patient, for at the point where the urethra 
was ruptured, an modular stricture, the worst of all strictures, may 
after awhile be formed. I am not aware that an urethrorrhagia, 
the result of an hemorrhagic diathesis, has been really observed, 
but such a case is not impossible. An instance of which has come 
under my own notice, and of which M. de Castelneau has published 
the details in the Annates de la syphilis et des maladies de la peau, 
would seem to belong to this category ; but the patient had suffered 
only from some trifling attacks of nasal hemorrhage, and there was 
nothing either in the antecedents or in what followed, to prove the 
existence of this diathesis. In this case the hemorrhage occurred 
in paroxysms, which sometimes lasted for an hour. After each 
attack the patient was so debilitated that he could not raise his 
arm. This example of an urethrorrhagia so grave in character, I 
believe to be unique. There was this remarkable fact in connec- 
tion with it, that during its continuance, as well as the intervals 
between these attacks, the muco-purulent discharge was suppressed, 
and it did not return until the urethrorrhagia was completely cured. 
It was for this reason that M. de Castelneau conceived the idea of 
a change in the modus operandi of the cause ; as it sometimes pro- 
duced a blennorrhagia, sometimes urethrorrhagia. This hypothesis, 



URETHRORRHAGIA. 121 

which, has been ably sustained by M. de Castelneau, is, however, 
after all hut an hypothesis. 

Diagnosis. — Hemorrhage from the nrethra may be easily distin- 
guished from that of the bladder. In the first case, the blood is 
not mixed with urine, and flows spontaneously ; in the other, it is 
at the moment of, or immediately after micturition that it appears, 
and is always more or less mingled with urine. Yery often, when 
a blennorrhagia is severe and deep seated, involving the neck of 
the bladder, with the last drops of urine may be noticed a clot of 
blood. In these cases the patient experiences severe pain when 
the stream of urine is voided, and vesical tenesmus. Sometimes 
the blood comes both from the urethra and the bladder ; we see, 
indeed, as has been already mentioned, patients discharging blood 
mingled with muco-purulent matter, in the intervals of micturition, 
as well as during the act. 

Prognosis. — Urethrorrhagia is not serious in itself, but it gener- 
ally indicates the existence of an intense urethritis, and may give 
rise to unpleasant consequences, especially if there be a rupture at 
any point in the urethra. 

[Mr. South states, in his edition of Chelius (vol. i. p. 178, Am. 
ed.), that he once saw an instance of enormous extravasation of 
blood, from the rupture of some vessel in the penis during the 
act of coition ; the penis and perineum were greatly distended, 
there was a severe pain in voiding urine, the evacuation of which 
required the use of the catheter. In the course of two or three 
days extravasation of urine ensued, and the bladder was punctured 
through the rectum. Sloughing in the perineum and groins oc- 
curred, and the patient had a very tedious recovery. — Gr. 0. B.] 

Life is not compromised by the loss of blood alone, and, in the 
most severe cases, the treatment consists simply in repose, and a 
milk whey diet, which suffices to arrest the hemorrhage. In the 
case already mentioned, after the hemorrhage had ceased, the ap- 
petite was keen, and the patient soon begged to be discharged from 
the hospital. 

Treatment. — This should be based on the cause of the hem- 
orrhage, and the quantity of blood lost. Generally, repose, diet, 
slightly acidulated or demulcent drinks, are sufficient to arrest the 
discharge, when it arises from excessive inflammation or a rup- 
ture of the urethra. If the patient be young, plethoric, and the 
urethritis subacute, to repose I add blood-letting, or what is better, 
the application of fifteen or twenty leeches to the perineum. Some 
practitioners, with Hunter, have employed copaiba. I have no 
faith in its efficacy, and am of the opinion that, in certain cases, 
this medicine might produce- an injurious effect, by irritating the 
neck of the bladder, and thus, to the hemorrhage from the urethra, 
add a bloody discharge from the bladder, which is an unfortunate 
complication. 

When the quantity of blood lost threatens the life of the patient, 
the remedies to be first employed, are refrigerants along the 
urethra, the scrotum, and the perineum. Sometimes alone they 
do not suffice to arrest the discharge ; in such a case, Benjamin 



122 VIDAL ON YENEEEAL DISEASES. 

Bell recommends compression of the urethra: it may be made 
from without inwards, or vice versa, or in both directions at the 
same time. "We may, indeed, by seizing the antiscrotal portion of 
the urethra between two fingers, employ compression sufficiently 
long to arrest the hemorrhage, or with a truss we may compress 
the urethra in the perineum. The compression in front of the 
scrotum may be effected by the application of little bands sur- 
rounding and compressing the whole penis. Should this be 
judged insufficient, we may resort to the use of bougies, or sounds 
which are to be introduced into the urethra ; if of large size, they 
may of themselves arrest the hemorrhage. If in spite of these 
means it continues, we join to the excentric, concentric compress- 
ion ; we apply narrow bands circularly around the penis, or the 
perineal truss, according to the depth from which the blood pro- 
ceeds. But, I must declare, that I have never had occasion to 
resort to these mechanical means. I repeat, therefore, that in the 
great majority of cases, repose and soothing applications are still 
the best and the most speedily effectual means. Further, in mak- 
ing the two kinds of compression mentioned, we may often obtain 
a contrary effect to that which is desired. It is well understood, 
that when we have to treat a hemorrhage from rupture of the 
urethra, after its cessation, and that of the urethritis, with which it 
is complicated, we must dilate the urethra with bougies, in order 
to prevent the formation of strictures. 



URETHRAL PAINS. 

Symptoms. — All the symptoms of blennorrhagia may disappear, 
with the exception of the pain : this not only continues, but may 
become exasperated, and constitute the only disease. It may be 
seated in any part of the urethra which has been inflamed, from 
the fossa navicularis to the neck of the bladder, but more fre- 
quently it is situated in the vicinity of the glans. This pain is 
sometimes of a shooting character ; it is constant, though occasion- 
ally exacerbated, and puts on the form of neuralgia ; it may be, 
though rarely, intermittent, and the attacks occur at irregular in- 
tervals. The actual severity of the pain can be generally but 
little known to the practitioner, for this accident occurs chiefly in 
nervous subjects, who are sometimes more or less hypochondriacal, 
and who always exaggerate their sufferings. Occasionally the 
pain is reflected from the bladder towards the anus and the rectum, 
and there is a feeling of weight in the testicles. 

Causes. — It is evident that urethral pain is more likely to be 
observed as one of the consequences of a blennorrhagia which has 
been imperfectly or improperly treated. 

A neglect of hygiene is also an actual cause of this accident. 
Yery excitable nervous subjects are those who suffer most from 
blennhorrhagia ; but it must be acknowledged that, in certain 
cases, neither age, nor temperament, nor the intensity of the in- 
flammation, nor a neglect of hygiene, nor errors in treatment, can 



URETHKAL PAINS. 123 

be accused. I have treated a patient who has been strict in his 
observance of hygienic rules, very precise in submitting to me- 
thodical treatment, and who was not of the nervous temperament : 
he suffered equally from urethral pains after the cessation of the 
discharge, and this pain resisted every plan of treatment. 

Treatment — For a long period, antispasmodics, narcotics, and 
blisters have been employed. John Hunter highly extolled the 
latter remedy, which he applied to the perineum. To these have 
been added, cold injections of opium and perineal frictions with a 
pommade of laudanum. Hunter speaks of injection, of a slightly 
irritating character, which are to be employed from time to time ; 
thus, we may use eight grains of corrosive sublimate to eight ounces 
of water. When these injections have produced a good effect, it 
has been but temporary. Bougies have also been employed, as 
well as sounds smeared with some particular ointment, or caustic. 
Thus, by the introduction of a large yellow wax bougie, I have 
sometimes diminished the irritability of the urethra. The bougie 
as it were toughens the mucous membrane of the urethra ; it seems 
to act like the bit in the mouth of the horse, of the presence of 
which after awhile the mouth becomes unconscious. By means 
of the bougie belladonna ointment has been introduced. Finally, 
the urethra has been cauterized after the method and with the in- 
strument of Lallemand. 

I have seen all these methods fail in the most skillful hands, 
and in cases which have been permanently cured by very simple 
means, viz. compression of the penis. 

Author's Treatment. — Compression. — I have observed that patients 
suffering from urethral pains, either as the result of blennorrhagia, 
or from certain morbid conditions of the neck of the bladder, often 
compress the penis with their fingers, and they have declared that 
in this way they obtain true relief. Again, I had observed, as 
have other surgeons, that calculous patients compress the glans, 
that they stretch the penis, and thus strive to ease their anguish. 
From this I conceived the idea of employing constant compression. 
This I effect by the methodical application round the penis of little 
bands of diachylon plaster, as follows : each little band should not 
be more than 4 lines in width : its length should be sufficient to 
encircle the penis, so as to permit the ends to lap each other under 
the urethra. The dressing is thus rendered more solid, and the 
urethral compression more certain. The bands should overlap 
each other, the second covering a third of the first, and so on with 
the rest. The compression should be very decided, but not carried 
to an extent sufficient to prevent the patient from urinating. These 
bands should be allowed to remain as long as possible, until the 
pains have ceased at least for three days. We should not fail to 
renew them, as they may become deranged, and fail to effect the 
object for which they were applied. This method of treatment is 
chiefly successful when the pain does not extend beyond the limits 
of the antiscrotal portion of the urethra. When it is seated in the 
perineum, there is less chance of causing it to disappear. In such 
cases, it sometimes becomes permanent ; generally it happens that 



124 VIDAL ON VENEREAL DISEASES. 

it is only moderated, but occasionally it entirely disappears. We 
may know in advance, if compression will succeed, by making the 
patient attempt it with his fingers ; if a momentary relief is ex- 
perienced, we have strong grounds for anticipating complete success. 
I should remark, in conclusion, that the pain may be caused by 
the remnants of an inflammation, in which case, leeching will 
be preferable to compression. In the Annates de la syphilis et des 
maladies de la peau, moreover, may be found facts recorded, which 
favor the practice here recommended.* 



PERVERTED SENSATIONS IN THE URETHRA.— ABSENCE OF 

SENSATIONS. 

Symptoms. — Instead of an exaltation of sensibility in the urethra 
which amounts to a pain, certain aberrations of this sensibility may 
be manifested as the result of blennorrhagia, which Benjamin 
Bell and M. Lagneau have denominated extraordinary sensations of 
the urethra. These sensations are also referred to the bladder, and 
in some instances to the testicles. Thus, after the cure of a blen- 
norrhagia and the cessation of the true accidents of this disease, 
there sometimes remains a modification of the normal sensibility of 
certain parts of the genitourinary apparatus. According to M. 
Lagneau, it is a continual titillation, a pricking sensation of the 
urethra, the vesiculas seminales, the neck and even the body of 
the bladder. There is also a kind of undulatory movement of 
the testicles (Benjamin Bell). Sometimes the symptoms resemble 
those of stone in the bladder. These abnormal sensations are oc- 
casionally felt not only in the genital, but in the pubic and hy- 
pogastric regions, and upper part of the thighs; sometimes the 
stomach itself, and the intestines become involved. It is not im- 
probable that in certain cases, these morbid feelings proceed from 
the stomach, particularly in hypochondriacal patients. 

Instead of an increased or perverted sensibility, it may be com- 
pletely wanting at some point of the urethra. Thus, after certain 
cases of blennorrhagia, . there may be an entire absence of the 
voluptuous feeling, which coincides with the ejaculation of semen. 
What is quite remarkable is, that the patient may indulge in 
sexual intercourse as usual, and the erections may be complete, 
but the ejaculatory act is unattended by the least pleasure, and 
the completion of coition is only made known by the cessation of 
the erection. 

[We have recently been consulted in relation to a case of this 
kind. If the patient indulge in a second connection shortly after 
the first, the ejaculatory act is then accompanied with a slight sen- 
sation of pleasure. — Gr. C. B.] 

This condition has been observed without any appreciable 
lesion of the urethra, as well as with an indurated and thickened 
state of the walls of this canal. M. de Castelneau has published an 
interesting case which belongs to this last variety. The patient 

* T. ii. p. 135. 



PERVERTED SENSATIONS IN THE URETHRA, &c. 125 

was cured by the application of leeches to the perineum, another 
fact corroborating the views which I have always professed, and 
which have guided my practice since I have been connected with 
so vast a theatre of observation. 

Attempts have been made to cure these abnormal sensations by 
means of yellow wax bougies, blisters to the perineum, hypogas- 
trium, and the internal surface of the thighs. Success has by no 
means always followed this mode of treatment. 

Causes. — Females are sometimes, though very rarely, affected 
with these perverted sensations, and when they do occur, it is 
generally owing to the fact, that there still remains a certain de- 
gree of irritation in the neck of the uterus, from the extension of 
the blennorrhagia to this organ. In such cases, there are most 
frequently venal and vesical difficulties, together with tenesmus, 
which greatly annoy the patient. These abnormal sensations oc- 
cur in both sexes, after every form of blennorrhagia, the mild and 
the severe, after attacks supposed to be syphilitic, as well as those 
which have been regarded as simply catarrhal. M. Lagneau is 
said to have observed these cases in men who have had what has 
been called a dry blennorrhagia. 

Patients who have suffered from these perverted sensations, 
firmly believe that the disease has been but imperfectly treated ; 
they are impressed with the idea, that a syphilitic virus still lurks 
in their system, and they dread its effects ; they incessantly de- 
mand to be radically treated, and especially by mercury or some 
other powerful remedy. 

Treatment. — There can be no doubt that antispasmodics and 
narcotics, used either internally or applied to the surface of the 
perineum, together with very small doses of the pil. hydrarg. to 
satisfy the imagination, sometimes produce beneficial effects. But 
still more frequently antiphlogistics are indicated ; for instead of 
a simply nervous state, there is, in reality, an urethral inflamma- 
tion with sympathetic phenomena. Therefore, these abnormal 
sensations, either of the urethra, testicles, or other parts of the 
genital sphere, cannot be made to disappear, until this inflamma- 
tion has been removed. I still repeat what I have stated in speak- 
ing of blennorrhoea : those who regard these morbid phenomena 
as the effects of a more or less protracted inflammation of the ure- 
thra (and, I will here add, of the prostate), will meet with greatest 
success in their treatment, since they will employ antiphlogistics. 
In these cases, I have not only applied leeches to the perineum, 
but have bled from the arm, for, as is well known, the condition 
in question is sometimes met with in young and vigorous subjects. 
When it is really a nervous affection, blisters succeed well, and are 
of greater efficacy than electricity. I should add, besides, that 
since the diagnosis of strictures and prostatic engorgements has 
become more perfect, fewer cases of extraordinary sensations of 
the urethra have been observed ; these phenomena are much more 
frequently and justly attributed to organic affections of the genito- 
urinary apparatus. 

[Mr. Acton has devoted a chapter to the subject of Monomania 



126 VIDAL ON" VENEREAL DISEASES. 

Syphilitica, or Syphilijphohia, a form of disease to which, he asserts, 
the medical profession is particularly liable ! (2d Am. ed. p. 401.) 
He states, that instead of simulating certain affections, or com- 
plaining of sensations for the purpose of misleading the practi- 
tioner, the syphilophobist describes only what by an exhalation 
of nervous sensibility he fully believes he sees or feels. Like 
hysteria, syphiliphobia assumes every form of venereal disease 
found or described in books. He observes that these cases are 
very numerous in London, and we think that in our own large 
cities, those who see many cases of venereal affections, must have 
met with instances of the kind. We doubt, however, whether 
they could corroborate the assertion, that it prevails particularly 
among the medical profession. In confirmation of Mr. Acton's 
statement, that these patients are very apt to lodge complaints 
against the testes, we subjoin the following case : Some few years 
since, we were summoned hastily, at midnight, to a patient's 
chamber. No sooner had we entered, than he presented his scro- 
tum, and directing our attention in turn to each of his testicles, 
with a doleful countenance, exclaimed, " Here, doctor, is Susan, 
and here is Mary ; cut them out /" With much difficulty we per- 
suaded him to defer the operation until morning ! We tried, in 
this case, as Mr. Acton directs, "moral treatment, very little 
physic, and much exercise," to no purpose,' and it was not until 
he became greatly emaciated, that some "Father Confessor" (the 
patient being a Catholic) effected what we had failed to accom- 
plish, viz. his restoration to health. — Gr. C. B.] 



BLEIfNORRHAGIC ORCHITIS. 

The history of inflammation of the testicles has recently made 
unquestionable progress. Of this we may be readily convinced if 
we go no further back than to the time of Dupuytren. For ex- 
ample, this surgeon asserts, in his Lecons, that when the epididy- 
mis is affected, the swelling is not as large as when the whole 
parenchyma of the testis is involved. The fact is precisely the 
contrary. Boyer is still less advanced than Dupuytren. Sir 
Astley Cooper had more correct views ; but the true progress in 
the history of this affection did not commence with him. The 
truth of these remarks will be obvious in the exposition of the 
additions to our knowledge on the subject, which I am about to 
attempt. 

Causes. — Although orchitis is an accident of frequent occur- 
rence, it is not an inevitable sequence of a blennorrhagia. Other 
causes are required for its production. Unfortunately these are 
not well determined. Nevertheless, it is certain, that this compli- 
cation of blennorrhagia occurs most frequently in patients who 
have been guilty of imprudence of various kinds during the exist- 
ence of the discharge, and who, among other excesses, have 
indulged in sexual intercourse. Some there are, who, though not 
guilty of the latter act, do not completely avoid excitement of an 



BLEOTORRHAGIC ORCHITIS. 127 

analogous nature. "When obstinate cases of orchitis are encoun- 
tered, when the inflammation passes from one testicle to the other, 
or when the disease reappears, these facts should not be forgotten. 

Improper treatment, or that which has been neglected, may cer- 
tainly exert an influence on the development of orchitis. Injec- 
tions have been much accused. Doubtless an irritating fluid may 
give rise to an orchitis, since the simple introduction of a bougie 
will, in some instances, produce the same effect. However, it 
must be acknowledged, that orchitis is not the accident most to 
be dreaded from the use of injections. One circumstance which 
has led to such a suspicion, is the fact, that they are generally 
employed in the last stages of blennorrhagia, a period most favor- 
able to the development of orchitis, as I shall hereafter establish. 

It should also be known, that this accident may occur, and not 
unfrequently, under hygienic conditions least favorable to the 
development of inflammation ; for example, whilst the patient 
observes complete repose, and is under the influence of proper 
treatment, not by irritants, injections, and the resins, but of that 
which is most antiphlogistic and soothing. At the present time, 
there is in my service a very robust patient, who has had three 
attacks of orchitis, attended with violent pains. This patient 
strictly maintained the horizontal position, observed a mild regi- 
men, and was guilty of no imprudence. Cases of orchitis have 
been seen to follow a hot bath, taken with every precaution. 

The intensity of the urethral inflammation seems to have no 
influence in the production of this disease. Of 37 patients, inter- 
rogated by M. de Castelneau, for the purpose of ascertaining this 
fact, 31 had suffered moderately at the commencement of their 
blennorrhagia, 6 had experienced acute pains, and one of these 
6 had had hemorrhage from the urethra so severe as almost to 
produce syncope. In this individual, orchitis appeared whilst he 
was confined to his bed, and while he was in a state of anemia 
from excessive loss of blood. 

Can a dry blennorrhagia give rise to this disease ? I prefer 
thus to propose the question. During the stage of urethritis, 
which is marked by an absence of the discharge, can orchitis oc- 
cur ? *[ reply in the affirmative, for I possess facts in corrobora- 
tion of such an answer. 

Certain seasons of the year, certain conditions of the atmosphere, 
favor the development of orchitis. Thus, I have occasionally ob- 
served, after sudden changes of temperature, the number of cases 
to increase, so as to appear almost like an epidemic. 

Generally, orchitis manifests itself after the first, second, and 
even the sixth week of a blennorrhagia. When treating of ure- 
thral blennorrhagia in the male, I stated, that in the majority of 
cases, the affection was seated, primarily, in the fossa navicularis, 
and the anterior portion of the urethra. Thence, at different 
periods of the disease, the inflammation gradually or suddenly 
reached the other portions of the canal. Orchitis does not gener- 
ally occur, until the inflammation has extended to the prostatic 
portion of the canal. When it does not appear until after the 



128 YIDAL ON VENEREAL DISEASES. 

cessation of the discharge, and, as we have observed, at the end 
of eight days in one case, of fifteen in another, we have reason to 
suspect the existence of an irritation in the region of the prostate, 
or the neck of the bladder. "We then find that the patients have no 
longer a discharge, that they suffer somewhat in urinating, having 
ardor urinse. As it is possible, on the other hand, for an inflam- 
mation to commence in the region of the prostate, or, at least, 
speedily to reach that part, it is easy to explain cases of orchitis 
which are met with either at the commencement, shortly after, or 
even before the appearance of a gonorrhoea. Orchitis exists al- 
ways with an urethritis, whether the discharge, the ordinary phe- 
nomenon of this inflammation, be present or absent. 

Age seems to exert no very marked influence in the production 
of this disease, though it may be observed that it is less frequent 
at an advanced age. Orchitis, involving the parenchyma of the 
testis, appears to be more frequent in persons about eighteen or 
twenty years of age, who are affected with blennorrhagia ; while 
in those more advanced, that is, from thirty -five, forty -five, and 
fifty years, vesical and prostatic affections are more frequent. 
However, there is now (March 5th, 1852) in my service, at the 
Hopital du Midi, two patients, aged thirty years, who have paren- 
chymatous orchitis. 

Orchitis may exist on both sides, but it is rare that both testicles 
are simultaneously affected ; generally but one is involved, and 
when the other becomes inflamed, it is after resolution has com- 
menced in the one first attacked. It is rare, but sometimes occurs, 
that orchitis passes rapidly from one testicle to another, without 
leaving traces of its first invasion. When one alone is affected, it 
is generally the left, and it is on this side that the inflammation 
begins when it involves both testicles. This may be explained by 
the fact that the blood is more easily returned from the right than 
the left testis. The epididymis is the part which is the first and 
most frequently affected ; in this part, also, the inflammation con- 
tinues for the greatest length of time. It is said that the discharge 
is sometimes suppressed when orchitis appears, or that, very fre- 
quently, its quantity is suddenly diminished. As a general rule 
it would be more correct to say, that during orchitis there is but a 
trifling discharge, and this for a good reason, viz., that the affec- 
tion occurs in the last stages of blennorrhoea, when the discharge is 
of course small in quantity. The diminution or suppression of 
the discharge has therefore preceded the invasion of the orchitis, 
at least such is the fact in the majority of cases. It would be 
wrong, however, to deny the influence of orchitis in diminishing 
or suppressing the discharge, for when the inflammation of the 
testis subsides, we generally observe its return. It may happen 
that both the urethritis and the orchitis cease at the same time. 
Examine, on this point, the statistics of MM. Gaussail, Aubry, 
and de Castelneau. Of 187 cases, in 161 the discharge diminished 
suddenly on the appearance of the orchitis, and in nine it was 
totally suppressed ; of fifteen which remained stationary, thirteen 
occurred to M. Aubry, who noticed that in all of the latter the 



BLENNORRHAGIC ORCHITIS. 129 

blennorrhea was of long standing, and the discharge small in 
quantity. 

Pathology. — A variety of opinions have been entertained as to 
the manner in which blenorrhagic inflammation invades the testis. 
It has been attributed to sympathy, to extension, and to metastasis. 
The doctrine of extension or propagation, along a continuous sur- 
face, is that which is now most generally admitted : the inflamma- 
tion extends from the urethra to the ductus ejaculatorius, from the 
latter to the vesiculae seminales, thence to the vas deferens, from 
which it reaches the epididymis. M. Yelpeau adopts this opinion, 
and has given the following account of the affection : 

" It would seem that the induration and swelling of the vas 
deferens must always precede that of the epididymis, if the inflam- 
mation always extends from the urethra to the testis ; such, 
indeed, is often the case. The epididymis, in certain patients, 
reaches to the inguinal canal and even to the iliac fossa. It is in- 
durated, painful, equal in size to a large quill, and sometimes even 
to the little finger, and it may readily be mistaken for the vas 
deferens. But it must be confessed, on the other hand, that this 
indurated cord is not a constant symptom ; that very often, indeed, 
the vas deferens and the whole spermatic cord are perfectly natural 
to the touch, insensible, and entirely normal, from the testis to the 
pelvis. If we carefully inquire into the early history of the case, 
we learn that pain, or uneasiness, is felt in the perineum, neck of 
the bladder, iliac fossa and inguinal canal, before it is perceived in 
the testis. After all, may not an inflammation be developed in 
the testicles nearly in the same manner as in the lymphatic glands, 
that is, by the retrocession or by the continuous progression of 
irritating particles from .point to point, from the urethra to the 
epididymis, without seriously involving the canal through which 
such particles are conveyed? Moreover, the inflammation itself 
may be limited to the mucous surface of the vas deferens, whence 
it sometimes reacts upon the whole thickness of the canal, so that 
the absence of swelling, induration, sensibility, or even pain at 
this part, may as readily be comprehended as where the opposite 
condition obtains. This is analogous to what is admitted, and 
daily observed in every kind of canal, and especially in the 
lymphatic vessels." 

M. de Castelneau, who has written a remarkable article on 
orchitis, and which is published in the Annales des maladies de la 
peau, defends the doctrine of a metastasis ; but, according to him, 
it is not the matter of blennorrhagia which is transported, but, if 
we may so speak, the cause. I confess, for my own part, without 
denying the production of orchitis by extension of inflammation, 
such as we sometimes observe to follow the passage of a bougie, or 
a sound into the urethra, I am strongly inclined to admit this doc- 
trine of metastasis, in a certain number of cases, for blennorrhagia 
is one of the diseases best adapted to this kind of displacement. 
Why is it that, in general, but one testicle is involved ? The ori- 
fices of the ejaculatory canals are in close proximity, and both 
should be liable to the same influences. Why is it, also, that in 

. 9 



130 VEDAL ON VENEREAL DISEASES. 

certain instances, orchitis passes rapidly from one side to the other, 
without leaving behind any trace of its existence on the side 
abandoned by the disease ? And why do cases occur in which 
the vas deferens does not become swollen until after the epidi- 
dymis? 

I believe, likewise, that inflammation of the prostate is some- 
times metastatic. Let me explain myself : I believe in the possi- 
bility of an affection of the neck of the bladder and the prostate, 
in cases of blennorrhagia, where the disease is seated in the ante- 
rior portion of the canal, and where it has passed over the rest of 
the canal to invade the gland and the neck of the bladder. It may 
happen even that the last-named parts shall be passed, and that 
the body of the bladder and the kidneys shall be attacked with 
blennorrhagic inflammation, while the intermediate tissues between 
the starting point and the organ last affected shall escape. Still 
farther, the articulations may become involved, as is well known, 
and surely no one in this case will pretend that the inflammation 
has extended along the continuous tissue of the skeleton, to reach 
these parts. It is said* that these facts favor the doctrine of sym- 
pathy as well as of metastasis, but this is a mere dispute for words 
alone. What I wish distinctly to establish is, that the doctrine 
which admits orchitis from extension of the inflammation from the 
urethra, is insufficient and incomplete. 

Symptoms, Progress and Termination. — Before any change is per- 
ceived in the testis we sometimes observe a febrile state, chills, 
restlessness, nervous phenomena, and even syncope. Generally, 
there is at first a sensation of weight in the scrotum, which causes 
the patient to apply his hands to the testicles, or to make use of 
a suspensary bandage ; sometimes pains in the loins are among the 
first symptoms : it follows a line extending from the kidneys to 
the scrotum. Some cases, indeed, commence with pains in the 
perineum, and a frequent desire to urinate, as in inflammation of 
the neck of the bladder. Frequently, there is at first a pain in 
the groin, and inguinal canal on the side affected, which pain 
may be very severe. Sometimes it extends towards the antero- 
superior spine of the ileum, and is soon felt in the testicle itself. 
The application of cold, the weight of the testicle whilst standing, 
walking, and particularly the jarring of the body, exasperate the 
pain and cause it to be reflected towards the corresponding kidney, 
rarely towards both. The heat and sensibility are greatly in- 
creased in the testis and epididymis, but not to the same extent in 
each. The sensibility often exists in an almost equal degree, and 
it is very rare that the pain is specially concentrated in the cord, 
and when such is the case, it is always, or almost always, in its in- 
ferior part. If the pain be sometimes very acute, this is not of 
long duration ; having reached its maximum point, towards the 
third, fourth, or fifth day, it generally begins to moderate, and in 
forty-eight hours more becomes supportable. After it has once 
moderated, its further decrease is very slow, sometimes requiring 
three weeks before it entirely disappears. This pain is always in- 
creased by pressure. In the last stages of orchitis, it is only when 



BLENNORRHAGIC ORCHITIS. 131 

the testicle is touched, that it is felt. Sometimes the testicle has been 
observed to be evidently swollen before any pain is experienced. 

The tumefaction begins occasionally in the cord, but more fre- 
quently in the epididymis ; it rapidly increases and reaches its 
height in the course of three, four, or five days. So speedy is the 
development of the tumor, that its progress cannot be followed. 
The swelling reaches from the size of a hen's egg to that of the 
patient's wrist, or it may become still larger. It is composed of 
all the parts which enter into the composition of the scrotum, but 
especially of the epididymis. In two or three days after the com- 
mencement of a severe orchitis, the tumor forms a homogeneous 
mass, of almost equal hardness throughout. The scrotum on the 
affected side is tense, shining, adherent to the subjacent parts and 
of a red color, the deepest shade being on the external surface of 
the inflamed testicle, whence it extends, though faded, to the sound 
testicle. At this period it is difficult to determine the precise seat 
of the tumefaction, for it is exceedingly sensitive to the touch ; but 
after two or three days, the mass being somewhat diminished, be- 
comes separated into two parts, the one more anterior is the testis, 
the other, posterior and superior, is the epididymis, which overlaps 
the other to a considerable extent. Sometimes owing to vicious 
conformation, which is not rare, the epididymis may be situated 
anteriorly. It is then in this direction that we observe the hardest 
portion of the tumor. We know that the induration and tumefac- 
tion are sometimes remarked over a more or less extensive portion 
of the vas deferens, but not in every case. The testis is generally 
but little augmented in volume, and its consistence is not changed : 
the swelling of the epididymis, however, is on the contrary much 
more decided. When there is a more or less marked effusion into 
the cavity of the tunica vaginalis, we may feel the fluctuation and 
assure ourselves of the existence of a fluid ; seldom is it sufficiently 
abundant to give rise to a transparency. 

Eesolution commences in the testicle, when the latter has been 
affected ; it regains its natural feel towards the fifth or sixth day. 
The rest of the tumor soon begins to subside, but resolution is 
here much slower in its progress, and in the majority of cases, it is 
not complete until from the fifteenth to the thirtieth day ; very 
frequently it is prolonged for a greater length of time. Eesolution 
in the cord succeeds that of the testis, after which follows that of 
the epididymis, which is the last in order, and which sooner or 
later occurs. The resolution in the epididymis differs from that 
in the other parts, not only by its slow progress, but by the nature 
of that progress. In the testis and the cord, resolution is perfectly 
regular in its progress ; in the epididymis, on the contrary, at first 
its course is rapid, and the anterior part of the organ is that in 
which it begins ; when the tumor has diminished one-half in size, 
its further diminution is very slow, and at the posterior and inferior 
part of the scrotum may now be felt a very hard nucleus, which 
is very slow to disappear. These nuclei have doubtless been the 
means of causing authors to assert that an enlargement of the epi- 
didymis often lasts during life. 



132 YIDAL Otf VENEREAL DISEASES. 

Should there be an effusion in the tunica vaginalis, the fluid is 
generally absorbed during the resolution of the other parts. 

The spermatic secretion during the existence of orchitis has been 
but imperfectly studied. M. Lagneau has mentioned a case show- 
ing that a patient affected with a swelled testicle of two months' 
duration, had had, during an amorous dream, a pollution mixed 
with streaks of blood. 

The fever accompanying orchitis is generally slight ; it exists 
only when the disease is at its height, and in cases where the local 
symptoms present a certain degree of intensity. M. Marc d'Espine 
in 24 cases of orchitis, found 17 in which fever existed at the com- 
mencement, and 2 in which it happened during a relapse, but in 
which it was absent during the primary affection. M. de Castel- 
neau has observed fever only in 11 out of 37 patients, a result 
which differs materially from that obtained by the observer above 
mentioned. But it must be remarked that patients present them- 
selves to us at a time when the general symptoms have disappeared, 
supposing of course that they had existed. Their own statement 
then is our only source of information. Now, as all patients are 
not equally intelligent, I required, says M. de Castelneau, as symp- 
toms of fever, a want of appetite and a decided heat of the skin. 

Sometimes there are pains in the loins, and in the extremity cor- 
responding to the side of the diseased testicle, with headache, nau- 
sea and vomiting. The renal pains as well as those in the inferior 
extremity, are explained by the nervous connections of the testicle 
with these parts and occasionally by a true complication on the 
part of the kidneys, when the pain reaches to such a height. 

Varieties. — The description of orchitis which I have given, is of 
modern origin. The recent progress of science and my own 
researches have enabled me to fix the seat of inflammation in 
different parts of the testicle, and to establish varieties based on 
this special seat. I know what arguments may be opposed to this 
localization. It is evident, that if it be objected that one tissue of 
the testis cannot be affected without involving another, this is a 
reasonable objection, and applies not only to this, but to every 
case which comes under the observation of the pathologist ; thus, 
when attempts are made to establish varieties of ocular inflamma- 
tion according to the structures involved, we meet with the same 
objection. But as regards the testicle, if it be maintained that by 
the term epididymitis we are to understand that the epididymis is 
more particularly inflamed, and if by conjunctivitis we are to un- 
derstand that the conjunctiva is more particularly inflamed, after 
these explanations no farther argument is required. Here, then, 
the testicle being composed of three parts, the epididymis, the 
tunica vaginalis, and the glandular parenchyma, I shall establish 
three varieties corresponding to these different parts. 

1. Epididymitis. — This is the most common variety. It is evi- 
dent, that if the starting point in every case of blennorrhagic 
orchitis is the urethra, if the cause be conveyed through the vas 
deferens, it should be more or less arrested by the convolutions of - 
this canal, that is, by the epididymis. Sometimes this part of the 



BLENNORRHAGIC ORCHITIS. 133 

testicle is affected, while the vas deferens remains sound, and then 
follows what is observed in certain cases of adenitis, the result of 
inoculation; we see, indeed, the gland affected by the virus or 
irritating cause, yet the vessel which transported this virus appa- 
rently preserves its complete integrity. It is thus, that we have 
inflammation of the epididymis from metastasis, or if it please, from 
sympathy. 

The swelling belonging to this variety is the most voluminous 
and irregular. The epididymis, when not well supported, becomes 
compressed and flattened on its sides ; it undergoes the most rapid 
changes, at least in the acute stage. When, from the anomaly to 
which I have already alluded, the epididymis is situated in front, 
the length of the tumor appears to be increased; it is almost 
cylindrical. 

Epididymitis is less painful than the two other varieties which I 
shall presently describe. 

What I have asserted in reference to the size of the tumor, where 
it is formed by the epididymis, may perhaps surprise the readers 
of the Lecons Orales of Dupuytren, who, as already stated, main- 
tains exactly the opposite opinion. On this point daily experience 
completely refutes the opinion of Dupuytren, and if any would 
judge for themselves, they have only to visit my wards at the 
Midi, or attend some of our public consultations. Moreover, we 
can comprehend how an inflammation which invades an organ like 
the epididymis, a dilatable body, should easily expand the tissues, 
while the substance of the testis, enclosed by a sclerous tunic much 
more unyielding than that of the epididymis, cannot expand beyond 
a certain point. 

The inflammation which makes such rapid progress in the 
epididymis leaves behind, nevertheless, indurated nuclei, the com- 
plete resolution of which is in general very slow. The seat of 
these small tumors is the part of the epididymis called the tail. 
These chronic inflammations, limited to small foci, are therefore 
but inflammations primarily acute, but which have become chronic. 
It happens also that these nuclei have a character primarily chronic, 
but then they proceed from some vice, and it is generally the 
tuberculous or syphilitic which gives rise to their formation or 
which protracts their existence. Tubercle especially is a frequent 
cause of chronic inflammation of the epididymis. Indeed, if it has 
not been preceded by blennorrhagia, and particularly if the tumor 
is very irregular and occupies but one side, no matter what the 
temperament or strength of the patient, tubercle is to be suspected. 

Varicocele is one of the effects of epididymitis, especially when 
the latter occurs on the left side, where a predisposition naturally 
exists to varices of the scrotum. 

In connection with epididymitis are observed very considerable 
engorgements of the vas deferens and the parts which surround it 
to fill up the inguinal canal. In these cases we sometimes find 
that the aponeuroses yield with difficulty to the swelling, thus 
causing a true strangulation, attended with many of the symptoms 
of strangulated hernia, such as pains in the abdomen, anorexia, 



134 YIDAL ON VENEREAL DISEASES. 

vomiting, and a tumor, the long axis of which follows the track 
of the inguinal canal, &c, &c. It may be distinguished from 
strangulated hernia by the antecedent circumstances, and the fact 
of the engorgement of the epididymis. When the cord becomes 
similarly engorged it gives rise to symptoms of peritonitis. 

2. Vaginalitis. — Inflammation of the tunica vaginalis does not 
exist in every case when there is found more or less fluid in its 
cavity ; if such were the case this variety of orchitis would cer- 
tainly be most common, and it would almost always co-exist with 
epididymitis. We know, moreover, that M. Eochoux has asserted 
that this fluid nearly always exists, as it is maintained again that 
epididymitis is always present, for which reason it is proposed to 
call every case of blennorrhagic orchitis, vaginalitis or epididymitis. 
But it is evident that the serous effusion generally constitutes but 
an epiphenomenon ; ordinarily there is, in the tunica vaginalis, a 
certain quantity of serum exhaled, because there is an engorgement 
of the vessels of the testicle. Indeed, when one of its principal 
parts is affected, especially the epididymis, it gives rise to dropsy 
of the tunica vaginalis, in the same manner as do certain abdominal 
tumors to ascites. This effusion is, properly speaking, passive; 
the opening of the tunica vaginalis gives exit to a limpid lemon- 
colored serum, but produces no perceptible effect on the progress 
of the orchitis. Sometimes, on the other hand, every circumstance 
goes to prove the existence of a true inflammation of the tunica 
vaginalis. The pain is sharp and constant ; the tumor decidedly 
tense; there is neither fluctuation nor transparency, and if the 
serous cavity be punctured with a lancet, the fluid evacuated is 
slightly muddy, of a reddish color, and very hot. After this oper- 
ation the pain is speedily relieved. The fluid is often reproduced, 
when it more nearly resembles that contained in chronic hydro- 
cele. I have sometimes seen, after this trifling proceeding, the 
testicle become swollen, occupy the place of the fluid, and a paren- 
chymatous orchitis rapidly succeed to a vaginalitis. 

If varicocele sometimes follows an inflammation of the epididy- 
mis, hydrocele is rather one of the consequences of inflammation 
of the tunica vaginalis. If we closely interrogate persons affected 
with hydrocele, we shall find a great number admitting that they 
had an acute affection of the testis, which is but a vaginalitis. This 
variety of orchitis has undoubtedly existed when we meet with a 
multilocular hydrocele. The swelling from vaginalitis is smooth 
and even, more or less globular, it extends much farther forwards 
than in the other varieties, and does not retain marks of pressure 
upon it as does the swelling from epididymitis. 

2. Parenchymatous Orchitis. — I have thought proper to apply 
this name to the inflammation which affects more particularly the 
parenchyma of the testis, and the substance contained in its firmest 
and most immediate envelope, the tunica albuginea. This va- 
riety I have remarked chiefly among the youngest subjects af- 
fected with blennorrhagia, about eighteen or twenty years of age. 
I have also observed it in persons not far from thirty years. Yery 
seldom, indeed, is this variety a primary affection. In these 



BLENNORRHAGIC ORCHITIS. 135 

rare cases the patients present certain symptoms which I will pre- 
sently describe, and there is no serum contained in the cavity of 
the tunica vaginalis, as I have proved by incision, of which I 
shall speak hereafter. Much more frequently, the parenchymatous 
orchitis has been preceded by an epididymitis. Sometimes it fol- 
lows a vaginalitis ; as I have already observed, I have emptied the 
cavity of the tunica vaginalis of the serum which it contained, 
and the next day I have seen the testicle become so tumefied as to 
fill the vacuum produced by the evacuation of the fluid. 

The swelling in parenchymatous orchitis is less voluminous than 
in the other varieties. Where it coincides with a vaginalitis and 
an epididymitis it forms a part of the general swelling, though 
less than that produced by the epididymitis, but more than that 
by the vaginalitis. The swelling resembles, though in an exagger- 
ated form, that of the testicle ; the mass is tense, and of an ovoid 
shape. Anteriorly it projects more considerably than does that 
of epididymitis, but less abrupt than vaginalitis when the effusion 
in the latter affection is small in quantity, for, when in vaginalitis 
there is but a thin layer of fluid, the swelling remains of an ovoid 
form. In the variety under consideration, the part of the tumor 
which belongs to the epididymis is with difficulty distinguished 
from that which belongs to the testicle itself ; all is one indurated 
and confused mass, covered by skin more or less red, and cellular 
tissue which is sometimes cedematous. The testicle is retracted 
towards the abdomen. 

This is the most painful variety ; it is attended with pains and 
cramps, which extend towards the groin, the iliac fossa, the kid- 
ney, and the inferior extremity of the corresponding side. Vom- 
iting and very decided symptomatic fever are present ; and it 
gives rise to reactions the most severe. This is explained by the 
seat of the inflammation ; the tissue affected being enveloped in 
a fibrous sac which resists its expansion, and which thus gives rise 
to a true strangulation. We can therefore understand the havoc 
caused by this inflammation when it is severe. It produces not 
only suppuration, but mortification of a portion of the testicle it- 
self, which is the more or less completely discharged. 

Treatment. — In the treatment of orchitis a great variety of 
methods have been adopted, and in my opinion without benefit. 
Local and general blood-letting have been employed, together with 
sedatives, purgatives, balsams, revulsives, all kinds of cold and 
hot topical applications, mercurial ointment, cataplasms, cotton, 
terra sigillata, vesicatories, compression, and, last of all, chloro- 
form. 

I am completely satisfied of the inefficacy, the impotence of 
these means in a curative point of view. Let me explain myself. 
I believe that the common blennorrhagic orchitis, that is, epididy- 
mitis with more or less effusion into the cavity of the tunica vagi- 
nalis, and a little irritation of the testicle, will pursue its course, 
in spite of any or all the means above mentioned. From this it 
must not be inferred that I am opposed to all treatment in all cir- 
cumstances of orchitis, in all its forms, for there are cases which 



136 VIDAL ON VENEREAL DISEASES. 

compel the practitioner to act temporarily, if for no other purpose 
than to mitigate the sufferings of the patient. 

1. Blood-letting. — Sedatives. — It is certain that in some very 
plethoric or nervous subjects, antiphlogistics and sedatives can- 
not cure orchitis, nor abridge the duration of this inflammation, 
but can only moderate certain symptoms. For example, a very 
high fever has more than once been lessened by general blood- 
letting, and the pain subdued at least for a time, by leeches, cata- 
plasms, of laudanum, aided by repose. 

2. Mercurial Ointment — The mercurial ointment, applied not by 
frictions, but in very thick layers, as in cases of peritonitis, and 
certain aithritic inflammations, may relieve the pain, and that too 
speedily. But if the mercury be continued under this form, a 
very unpleasant salivation may sometimes be produced. I am 
convinced that in certain young subjects, the ointment thus em- 
ployed may prevent vaginalitis and parenchymatous orchitis. 

3. Purgatives. — I believe that the repeated use of mild purgatives 
may promote the dispersion of some of the indurated nuclei of the 
epididymis, and that in the acute stages it is often necessary to 
remove the constipation. But, I repeat it, the ordinary course of 
an orchitis is not abridged by any of these means. 

4. Compression. — This is of difficult application ; the little bands 
which are used become easily loosened, and from the irregular 
form of the tumor, they act more on certain points than others. 
Besides, pressure cannot be borne in severe cases, where the in- 
flammation runs high, and when the latter involves the tunica 
vaginalis, and especially the parenchymatous structure, as it does 
in certain cases of epididymitis ; by compressing the tumor under 
such circumstances, we may produce symptoms of strangulation. 
The suffering excited, in some instances, by handling the tumor 
for the purpose of examination, enables us to form some idea of 
that which the patient must endure from the application of com- 
pression. 

[Our author, though differing in his estimate of compression 
from some of the highest authorities, among whom may be named 
Messrs. Eicord, Acton, South, Langston Parker, and Egan, is yet 
far more moderate in his condemnation of this method (Fricke's 
of Hamburgh) than is Mr. Henry James Johnson. At page 212 
of his " Treatise on Diseases of the Genito- Urinary Apparatus" he 
remarks, that from the torture he has seen patients undergo who 
have submitted to it, he "is inclined to compare it to the process 
of the Buccaneers of the Spanish Main, who slung their prisoners 
to the yard-arm by the testicles, until they had confessed where their 
dollars were concealed. If the inflammation is acute, it is a piece of 
ridiculous cruelty ; if mild it is disproportionately painful, trouble- 
some to manage, apt to lacerate or excoriate the skin, and not a 
little treacherous." We think that the majority of practitioners 
who have tried this plan, will agree with Mr. Johnson in his re- 
marks on the difficulties in its application, and the accidents to 
which, from its exceedingly great liability to become deranged, it 
ia apt to give rise. Even M. Ekord cautions us to be attentive to 



BLENNORRHAGIC ORCHITIS. 137 

these matters, if we would avoid unpleasant consequences. At 
page 177, of his 2d ed. of Hunter, he describes the conditions to 
which this treatment is applicable. When the spermatic cord is 
not too much engorged, and the cellular tissue of the scrotum is 
not the seat of a phlegmonous inflammation, when there is no ten- 
dency to suppuration or abscess formed, when the inflammation 
has been subdued by antiphlogistics, and when, if complicated 
with hydrocele, the cavity of the tunica vaginalis has been emp- 
tied, he considers Fricke's method superior to any other plan 
of treatment. If in the course of half an hour or an hour after its 
application the patient experiences no relief, but an aggravation 
of his sufferings, he directs that it should be at once removed, and 
mercurial ointment with fomentations or emollient cataplasms 
substituted. Mr. Langston Parker, p. 73, 2d. ed., states that he 
has repeatedly employed Fricke's method from the very com- 
mencement of the disease with the most complete success, and 
Mr. Egan, p. 104, of his excellent treatise, states that he does not 
remember to have witnessed a case in which its employment was 
not followed by speedy and permanent relief, and Mr. Acton 
thinks it has superseded the thousand and one remedies formerly 
employed (2d Amer. ed. p. 144). From what we have seen of it, 
we would advise the young practitioner, before resorting to it, 
to bear in mind the indications mentioned by M. Ricord, and 
the objections urged against it by Mr. Johnson and our au- 
thor.— a. C. B.] 

5. Chloroform. — This substance, when topically applied, produces 
at first severe pain, and I have had an opportunity of seeing a 
partial peritonitis from the employment of chloroform according 
to the method of M. Bouisson, who has highly extolled this plan 
of treatment. 

6. Puncture of the Tunica Vaginalis. — M. Velpeau. — If it be true 
that the treatment ordinarily pursued does not retard the progress 
of orchitis ; if leeching and compression are incapable of promot- 
ing resolution, operative medicine, properly speaking, may put an 
end to the accidents, or abridge the duration of the disease. "When 
there is actually a vaginalitis, and a subacute hydrocele is formed, 
the puncture of the tunica vaginalis as first practised by M. Vel- 
peau, may favor resolution and promptly relieve the pain. This 
puncture is made with a lancet or sharp pointed bistoury; it 
should be half an inch in extent. As soon as the instrument has 
penetrated the serous cavity, a demi-rotatory movement should 
be given it, by which the borders of the little wound will be sepa- 
rated, and the discharge of the fluid facilitated. The lancet should 
not be withdrawn until the fluid has been completely evacuated, 
that the lips of the wound through the integuments and serous 
membrane may preserve their parallelism, and the issue of the 
liquid be not prevented. 

7. Incision of the Testis. — Author's Method. — In cases of paren- 
chymatous orchitis, puncture of the tunica vaginalis is not suffi- 
cient ; the inflammation is then accompanied by strangulation, for 
the organ affected is surrounded by a very dense fibrous sheath. 



138 VIDAL ON VENEEEAL DISEASES. 

This is the variety of orchitis which I remove by an incision of 
the testicle. I puncture the tunica albuginea with a lancet or 
sharp-pointed bistoury, the opening being little more than half an 
inch in extent. This operation is attended with no more pain 
than that of puncturing the tunica vaginalis. Its safety is estab- 
lished beyond a doubt. I have operated on more than 400 pa- 
tients in private practice, and at the Hopital du Midi. My internes 
have often performed it in the night, during an exacerbation. It 
has never been followed by the least accident, and generally, in 
half an hour or an hour, the patient is greatly relieved. He sleeps 
the whole of the following night, and sometimes the following day. 
I have adopted this plan of treatment when other energetic meas- 
ures have failed. The result has been the same : relief prompt 
and decided. But this trifling operation is not only sedative, it is 
antiphlogistic, a powerful resolvent, and a certain preventive of 
suppuration, and the consequent disintegration of the testicle ; for 
after the puncture, the tumor is rapidly dispersed. The great 
number of these operations which I have practised may give rise 
to an impression that I have performed it in other varieties than 
the parenchymatous orchitis, in which suppuration is not of fre- 
quent occurrence. Indeed, when I became satisfied of the inocu- 
ous character of these punctures, I extended their employment to 
cases of epididymitis with swelling of the testicle, acute pain, and 
more or less sympathetic disturbance. In these cases, also, I have 
relieved the pain, removed the symptoms, and expedited the cure. 
For example, in one instance, by some anomaly, the epididymis 
was carried forwards and downwards. Inflammation in this part 
produced a tumor, which I mistook for a swelled testicle. I there- 
fore cut the epididymis, by which proceeding the pain was re- 
lieved, the sympathetic disturbance removed, and resolution 
greatly promoted. These punctures, then, are useful not in the 
treatment of parenchymatous orchitis only, as I at first proposed 
and practised ; they are beneficial not in the treatment of vaginal- 
itis only, as M. Velpeau has often proved ; but they may also pro- 
mote the resolution of an epididymitis, and prevent the accidents 
which this inflammation might produce. 

To this operation objections have been made ; it is supposed 
that by it, a large incision is made in the organ, and great fears 
have been expressed for the safety of the tubuli seminiferi, which 
must be wounded and obliterated, whence must follow atrophy of 
the testicle, impotence, and sterility ! Now the fibrous envelope 
of the testicle is divided to the extent of little more than half an 
inch in length, and less than half in depth. With every precau- 
tion, some of the tubuli seminiferi may be reached, but is it possi- 
ble for the obliteration of a few of these innumerable ducts to 
produce atrophy of the testicle, and to render the patient impotent ? 
As to the production of atrophy, I can speak from great experi- 
ence, for all of my patients have been strictly watched in reference 
to this matter, and that too for a long time after the operation ; 
and in no instance has the testicle become diminished in size or 
consistence. There is no reason to apprehend impotence or ster- 






BLEIs T XORRHAGIC PROSTATITIS. 139 

ility, for even though but one other testicle remains, it is difficult 
to comprehend how the obliteration of some of the tubes of one 
testicle should destroy the functions of the other. In certain 
tubercular affections of the testicles, both of these organs are 
partly destroyed, and yet the patient is not generally rendered 
impotent. Further, if we wish to obliterate a great number of 
these tubes, the best method is to permit the inflammation to pur 
sue its course, and the suppuration which follows will be sure to 
effect our object. Now, nothing but a trifling incision can arrest 
the progress of an acute inflammation of the parenchyma of the 
testicle itself. "What is most extraordinary, the two most able 
and experienced surgeons who have opposed me in this matter, 
have made the same and the least important objection to the 
practice. Since then, one of these same surgeons has claimed to 
be the inventor of this proceeding ! M. Velpeau has remarked 
that this operation alarms both patient and practitioner. Who 
has ever been frightened at a simple puncture of the tunica vagi- 
nalis ? Patients daily submit to it without hesitation, for the ope- 
ration is daily performed by the practitioners whom I have men- 
tioned. Now, when we are puncturing the fibrous envelope of the 
testicle, does the patient know whether we penetrate a few lines 
more deeply? Practitioners, I am sure, must derive confidence 
from the numerous facts which daily occur in favor of this 
method. 

BLENNORRHAGIC PROSTATITIS. 

Chronic engorgements of the prostate have in modern times 
been carefully studied. Home, J. L. Petit, and very recently MM. 
Mercier and Civiale, have devoted much attention to these affec- 
tions as observed in old people. But acute prostatitis, that which 
is met with in persons under fifty years of age, and which is one 
of the accidents of blennorrhagia, has been much neglected. 
Doubtless, those authors whose attention has been directed to the 
subject of urethral blennorrhagia, must have noticed certain symp- 
toms of prostatitis; thus Benjamin Bell has briefly described its 
history upon which I shall soon enter, but its complete history 
has yet to be made and detailed, and authentic facts for the pur- 
pose are still wanting. I will here insert the histories of three cases, 
they will be of service to those who will hereafter attempt a com- 
plete description of blennorrhagic prostatitis. The particulars of 
these cases were collected by M. de Castelneau, while he was my 
interne at the Hopital du Midi. 

Case 1. Diot, set. 40, a market-house porter, with brown hair, 
black eyes, dark skin, of ordinary height, muscles well developed, 
entered the Hospice duMidi, Ward 10, No. 5, on the 6th Feb., 1843. 
His health had always been good, having never suffered either 
from syphilis nor any other malady. On the 1st Jan. he had con- 
nection with a widow woman, who was not menstruating. He 
knows not whether she was diseased. At the end of four days, 
there was a slight discharge from the urethra unattended with 



140 VIDAL OX VENEREAL DISEASES. 

pain. Tins discharge continued about the same for ten days, when 
he experienced a prickly sensation in urinating, this was soon fol- 
lowed by frequent desires to urinate. The urgency of these de- 
sires increased, and became finally so irresistible that the patient 
was obliged to satisfy them wherever he might be, under the 
penalty of passing his urine involuntarily. After eight days, to 
these symptoms was added a greater or less difficulty of urinating, 
which, since yesterday, has become converted into a complete re- 
tention, and thrown the patient into a state of great anxiety. 

After his admission, the catheter was introduced, which entered 
the bladder with the greatest facility, and without producing more 
than ordinary pain, its pavilion having only been turned a little 
to the left, when its beak reached the region of the prostate. 
About twenty ounces of urine were forcibly evacuated. The 
urethra is the seat of burning, pricking, shooting pains throughout 
its entire length, which are felt most severely deep in the perineum. 
This pain prevents the patient from sitting, and causes him to 
groan continually. An examination per rectum, detects a tumor 
with a squared surface, so to speak, and presenting two lateral bor- 
ders, nearly parallel with the direction of the intestine, and two 
other edges, the one anterior, the other posterior and perpendicular 
to the first. The surface by which these borders are intersected, 
may have about two inches in extent from one side to the other. 
The angle formed by the junction of the right and posterior bor- 
der, is much more salient than that formed by the posterior and 
left. This salient angle, more or less decided, exists throughout 
the whole length of the tumor. Pressure on this tumor is insup- 
portable ; to the touch it presents the same feel as a phlegmonous 
tumor offering an obscure sense of fluctuation. There is but a 
very small discharge of a sero-mucous nature from the urethra. 

The face of the patient is red, the conjunctiva injected, the eyes 
prominent ; the heat of the skin is increased, and the pulse is 
about 100. He neither eats nor sleeps. The use of the catheter 
afforded some relief. Prescription : orange Tillen tisane ; thirty 
leeches and cataplasm to the perineum ; diet. Evening : the pain in 
the perineum has somewhat abated, but the retention of urine is al- 
ways complete. The catheter is again introduced with the same 
facility, its handle being always a little deviated laterally when the 
break arrived at the prostatic portion of the urethra. No change of 
remedies. 

Peb. 7th. — Morning : patient did not sleep last night, and it be- 
came necessary to use the catheter at 3 o'clock in the morning, 
which instrument has always been very readily introduced. The 
tumor when examined by the rectum, presents the same volume 
as yesterday. In other respects the same as last evening. Pre- 
scription : twenty -five leeches to the perineum, followed by a cata- 
plasm, two pills of opium and camphor, camphorated lavement ; 
hip-bath ; other treatment unchanged. 

8th. — The tumor has sensibly diminished in volume ; it is soft 
and has a feeling of fluctuation ; on pressure the pain is about 
the same, but less spontaneously ; the lavement brought away one 



BLENNORRHAGIC PROSTATITIS. 141 

stool, which, caused severe pain in the tumor. In the night the 
patient was able to expel some drops of urine ; nevertheless it was 
necessary to use the catheter, which as before was introduced with 
perfect ease. The urine was expelled in jets the same as before : 
slept none, countenance a little less anxious, pulse 90, and weaker. 
Same prescription, but fewer leeches. 

9th. — Scarcely any change ; the patient, however, suffers some- 
what less, but can pass his urine only in drops. The tumor 
seems to be diminishing in size, at least on the side of its salient 
angle. Catheterism as before. Pulse from 85 to 90, still very 
strong ; heat of skin somewhat more than natural. Same prescrip- 
tion, ten more leeches to the perineum, and diminish the quantity 
of fluid used in the lavement. 

10th. — Marked improvement : has passed a glass of liquid 
at seven or eight different times, drop by drop : catheterism not 
required during the night ; slept a little ; pain less severe in the 
urethra and perineal region, except on pressure, when it is still 
very great. The finger introduced into the rectum, discovers that 
the angle so salient on the right side, is almost completely effaced, 
and the tumor is but little more prominent on this than on the 
left side ; throughout its whole extent it has equally diminished, 
and has assumed a softer consistence. Heat of skin nearly nor- 
mal ; pulse of less force and from 70 to 75 ; appetite feeble. The 
urethral discharge has become somewhat opaque and a little more 
abundant, but nothing passed which leads to a suspicion of the 
opening of an abscess in the urinary passages. Heat of skin nor- 
mal ; pulse more feeble and 70 ; appetite good. Catheterism is 
practised this morning with the ordinary facility. Tillen's tisane, 
cataplasm on the perineum, prolonged hip-bath ; broth twice. 

11th. — More than two glasses of urine passed without the 
aid of the catheter, and almost entirely drop by drop ; at times 
only when the patient makes a powerful effort, the urine issued in 
a very fine stream, which ceased almost immediately. The cathe- 
ter was used only once last evening. The tumor examined per 
rectum continues to diminish in size, especially, at its angles which 
are more and more effaced. Pain even on pressure slight. Sleep 
has been interrupted only by the constant frequent desire to uri- 
nate. Appetite very sharp, pulse and heat natural. Same pre- 
scription, with the addition of soup twice. 

From this time the patient continued uninterruptedly to im- 
prove, and urinated with more facility. February 18th, the urine 
is passed almost without pain, though more frequently than na- 
tural. February 26th, urine is passed without difncult} r . The 
tumor steadily diminishes, and is quite insensible to pressure. 
"When the patient left there was no unnatural projection in the 
rectum. The urethral discharge diminished in proportion to the 
increase of inflammation of the prostate. February 28th, it is 
almost as copious as before the supervention of the above-named 
accidents. From this period to the 11th March, 1 drachm of tur- 
pentine was daily used without benefit ; then cubebs were em- 
ployed in increased doses, even as high as 5 drachms daily. On 



142 YIDAL ON VENEREAL DISEASES. 

the second day of its administration, the discharge had perceptibly 
decreased. On the sixth it had completely disappeared. The use 
of this medicine was continued until the patient left, and the dis- 
charge did not return, although, for five days before he left, he 
had spent part of the time in the garden. His food has been grad- 
ually increased to its natural quantity, and yet his digestion has 
not been disturbed. In fine, the patient left the hospital on the 
3d April in perfect health. 

I know of no more complete or conclusive case on record. 
Here we see a prostatitis following close on to a blennorrhagia. 
The disposition to urinate was constant, the retention of urine 
complete. The pain in the perineum was so severe that the 
patient was unable to sit. The prostate was considerably enlarged. 
During the prostatitis there was but a mere weeping from the 
urethra. The catheter was introduced with ease ; it was turned 
from its course laterally, showing that one lobe of the prostate was 
larger than the other, a fact which was proved by examining with 
the finger introduced into the rectum. The subsidence of the dis- 
ease was coincident with the reappearance of the urethral discharge. 
The resolution of the tumor formed by the prostate was complete, 
proving that it depended solely on an acute inflammation. The 
application of leeches succeeded perfectly. 

Case 2d. — Collat, get. 27, printer, was admitted July 8th, 1844 : 
constitution robust ; for some years had" been subject to rheumat- 
ism. About three weeks since, four days after an impure connec- 
tion, this man was attacked with blennorrhagia. The discharge 
became speedily white, thick, very copious, but the pain was not 
severe in urinating. On the 6th July, there was scarcely any pain 
whatever. That evening he indulged excessively in alcoholic 
drinks ; the next day he could not urinate. In this condition he 
passed Sunday, the 7th July, and on Monday morning he sought 
relief. 

July 8th. The face is pale and anxious ; pulse feeble ; body 
bent forward, hypogastrium tense and painful ; frequent disposi- 
tion to urinate, impossible to be satisfied ; a sense of weight in the 
perineum, tenesmus in the lower part of rectum. The dulness in 
the hypogastrium extended to the umbilical region. Nearly two 
and a half quarts of urine were drawn off by the catheter (the 
patient having passed none in forty hours) ; the instrument was 
easily introduced, its passage through the prostatic region alone 
having been attended with pain, but the surgeon encountered no 
obstacle. A rectal examination detected a marked enlargement of 
the prostate. Buttermilk ; twenty leeches to the perineum ; a 
soothing lavement ; diet ; and the introduction of the catheter three 
times in twenty -four hours. 

9th. The leeches drew but little blood ; treatment not changed ; 
a hip bath ordered. Faeces more freely passed, but at the time of 
their evacuation, the patient experiences pain and decided vesical 
tenesmus. The catheter used three times. 

10th. Improvement ; less frequent disposition to urinate ; and 
the patient passes only some tablespoonfuls of urine ; size of the 



BLENNORRHAGIC PROSTATITIS. 143 

prostate diminished. Buttermilk ; twenty leeches to the perineum , 
catheter used twice in the twentj-fonr honrs. 

11th. Much blood discharged by the last leeching; great im- 
provement ; the prostate reduced nearly to its natural size. Gen- 
eral bathing ; catheter still used twice. 

12th. Patient has passed without the catheter, during the night, 
at different times, nearly a pint of urine. Prolonged general bath- 
ing ; catheter used once during the evening. 

13th. The examination, per rectum, shows that the prostate is 
not enlarged. The catheter is no longer required. Indeed, he 
passes his urine well, after considerable intervals, and in a con- 
tinuous stream. The blennorrhagia has reassumed an acute char- 
acter, the discharge is white, thick, but unattended with pain. 

20th. Tisane of fir-tree buds, and powdered cubebs. The dis- 
charge gradually disappeared, and the patient left cured on the 
31st July. 

In this case, the blennorrhagia was already of long standing. 
It should be remarked, that the exciting cause was the excessive 
indulgence in alcoholic drinks, which was almost immediately fol- 
lowed by prostatitis, since on the next day the retention of urine 
was complete. 

Case 3d. B. set. 30 ; admitted 10th June, 1844. Constitution 
not very robust; temperament lymphatic; usual health good. 
About eight months since this man contracted a blennorrhagia. 
No regular treatment was followed, having been interrupted by 
excesses of every kind. Each relapse was followed by acute 
symptoms, which diminished of themselves whenever the patient 
conducted himself properly, and observed repose. On the 9th 
June, this man drank immoderately of spirituous liquors, indulged 
repeatedly in sexual intercourse ; in the night found it impossible 
to urinate, and on Monday morning was in the same condition. 
He then sought advice. His state was as follows : countenance 
pale and anxious ; skin cold ; pulse feeble ; his body was bent 
forward as if by some irresistible force. The bladder was dis- 
tended by a large quantity of urine ; there were sharp pains in the 
lower part of the belly, and a sense of weight in the perineum, 
neither pain nor tenesmus in the lower part of the rectum. A 
rectal examination detected a very decided enlargement of the 
prostate, which is hot, but little painful, except on strong pressure. 
The catheter was used as soon as the patient was admitted. At 
least three and a half pints of urine were withdrawn. The instru- 
ment was introduced without difficulty, yet on passing the pros- 
tate region it excited an abnormal sensation. Milk- whey ; twenty 
leeches to the perineum ; diet. In two hours the vesical tenes- 
mus was as strong as in the morning. Catheter used at two 
o'clock, at six o'clock in the afternoon, and at eleven o'clock in the 
evening. 

June 11th. No change ; bfadder still distended ; patient unable 
to expel the least drop of urine ; no effect from treatment ; no 
blood drawn by the leeches. General bathing ; |wenty leeches to 
the perineum ; diet. Catheter used four times ; during the even- 



144 YIDAL ON VENEREAL DISEASES. 

ing leeches again applied, the first not having taken : six only drew 
blood ; thus, of sixty leeches, only six were of any use. 

12th. No change; same prescription. Leech bites now dis- 
charge freely ; and an improvement is manifest ; at 11 o'clock in 
the evening the finger passed into the rectum detects a decided 
diminution in the size of the prostate ; catheter, however, had still 
to be used four times. During the night, by great efforts, the 
patient succeeded in passing about half a glass of urine at different 
times. 

13th. This morning the bladder is still distended, but the hypo- 
gastric pain is less. The patient craves food. ISTo fever. Milk- 
whey ; prolonged general bathing ; soothing lavement ; and some 
broth were ordered. Catheter used only three times in twenty-four 
hours. 

14th. Patient begins to urinate himself. Prostate still diminish- 
ing in size, having nearly regained its natural dimensions ; catheter 
still required twice a day, morning and evening, until the 16th 
June. Milk- whey, twenty leeches to the perineum ; soup twice. 
Improvement continues. On the 17th, enlargement of prostate 
gone ; and patient passes his urine naturally. 

When the patient was admitted there was but a slight weeping 
of serum from the urethra ; now the discharge reassumes its acute 
form. The right epididymis is swollen. Ordered rest in bed; 
cataplasms over the swelling ; light nourishment. June 30th, tisane 
of fir-tree buds, powdered cubebs five drachms. Patient left cured 
on the 10th July. 

In this case, too, the prostatitis was caused by the immoderate 
indulgence in alcoholic drinks, and by other excesses. The en- 
larged gland was hot, but less painful than in the other examples. 
The reappearance of the urethral discharge coincided with the 
subsidence of the prostatitis. 

In all three of these instances we observe that the disease 
occurred in persons upwards of thirty years of age. As in the 
case of orchitis, it is not the severer forms of blennorrhagia which 
produce it. In the three cases cited the discharge was slight, the 
exciting cause, excessive indulgence in alcoholic drinks, and a 
complete retention of urine followed, which might have led to the 
suspicion of obstruction in the urethra, or even a paralysis of the 
bladder. The catheter, nevertheless, was readily introduced, and 
the urine passed in jets through the instrument. It should, how- 
ever, be remarked, that the passage of the catheter through the 
prostatic portion of the canal, was attended with pain. The cure 
always coincided with an increase of the discharge. If we adopt 
Benjamin Bell's divisions of blennorrhagia we should say that it 
had passed into the second or third degree. 

How shall we explain the retention of urine and the facility with 
which the catheter was introduced in the case of a prostatitis ? We 
know that the gland may be enlarged? throughout its whole extent, 
or that this enlargement may be confined to one of its lobes. In 
the latter case the middle lobe is most frequently affected. When 
the patient would void his urine this enlarged lobe presses against 



BLENNORRHAGIC PROSTATITIS. 145 

the commencement of the urethra and obstructs the passage of the 
urine. The latter, in trying to pass, by its pressure against this 
lobe, produces a kind of valve, which the catheter, on the contrary, 
easily thrusts aside. The same occurs when one of the lateral 
lobes alone becomes enlarged ; the tumor may cause the urethra 
to deviate towards the opposite side ; it still acts as a valve ; in 
this case the catheter passes readily into the bladder and rectifies 
the prostatic portion of the canal. Once in the bladder we feel 
that this instrument is turned to one side, as in the case first 
reported. 

In an old man we might suspect a paralysis of the bladder ; but 
what happens then? The catheter reaches this organ but the 
urine drivels away, while in the three cases just detailed it issued 
in a strong and continuous stream. 

In the three cases observed by us, the patients complained of 
anal and vesical tenesmus, and of sharp pains during defecation ; 
the examination per rectum detected a tumor corresponding to the 
situation of the prostate, in one (the first) case it presented a feeling 
as if it had been squared. Except in one case this examination was 
very painful, the tumor was hot, and had the elastic feel of an 
inflamed testicle. The pain was increased by sitting, walking, or 
crossing the legs. In one case the patient's body was strongly 
bent forwards and could not be straightened. 

[Mr. John Adams, of the London Hospital, in his recently -pub- 
lished work on the Anatomy and Diseases of the Prostate Gland, 
states that a swollen state of the hemorrhoidal veins, forming 
external piles, frequently accompanies this distressing disease, and 
that these are attended with painful itching sensations around the 
anus and weight in the perineum, materially increased when the 
patient is in the erect position. He also confirms our author's 
remarks, that prostatitis may occur in the chronic as well as in the 
acute stage of blennorrhagia, and that the patient is liable to it on 
exposure to cold and wet, or any other exciting cause,, though a 
gleet only remains. He states that one of the most severe cases 
he ever saw occurred in a patient twenty-seven years of age, who 
had only a slight gleety discharge. In this case, as well as in 
those reported by our author, "there was no difficulty in the intro- 
duction of a moderate-sized silver catheter," though the retention 
of urine was complete. . After perusing Mr. Adams' report of this 
case, our author's explanation of the facility in which the catheter 
is introduced in prostatitis, seems, to us, quite satisfactory. The 
remarks of Mr. Adams on this disease are worthy of careful 
study.— G. C. B.] 

The treatment in all was the same ; the repeated application of 
leeches in large numbers to the perineum, which caused a sub- 
sidence of the symptoms, as already mentioned. With the removal 
of the prostatitis we have seen the return of the blennorrhagia. 

I have already stated that Benjamin Bell had imperfectly 
sketched the history of blennorrhagic prostatitis. He established 
the fact, that it may set in gradually or become at once developed, 
that is, by the extension of the urethritis, when the latter is already 

10 



146 VIDAL ON VENEREAL DISEASES. 

of long or very recent standing. He asserts, what is possible, that 
the prostatitis may occur suddenly when the commencement of the 
urethra is inflamed, without requiring an affection of the interme- 
diate points of the canal ; in which case there is a kind of metastasis. 
Benjamin Bell, with reason, extolled the use of lavements, con- 
sisting of: 

]J. Tinct. Opii. iRxxx. 
Amid on. § ii. 
Aq. q. s. 

Inject gently into the rectum. An excellent method of relieving the 
vesical pains, and tenesmus. 

According to Bell, it is better to promote than to suppress the 
discharge, that is, to diminish the inflammation by degrees. For 
this purpose he placed great dependence on bloodletting. He pre- 
scribed astringent or emollient injections, which was wrong, inas- 
much as nothing, in acute prostatitis, can be more injurious than 
the introduction of liquids into the urethra. 



BLENNORRHAGIC CYSTITIS. 

There are two different methods of treating blennorrhagia, which 
in my opinion are equally dangerous ; viz. that which attacks it 
violently at the onset, and that which consists in an almost com- 
plete inaction. Both of these plans may lead to a chronic dis- 
charge, and the extension or displacement of the disease. Thus, 
it is remarkable, that all the probable cases of nephritis are more 
or less connected with blennorrhagia ; it is remarkable, I say, that 
all of these patients had taken Chopart's potion, or some other 
resinous anti-blennorrhagic. Inflammation of the neck of the 
bladder, or of the bladder itself, is not rare, after the use of these 
means. But by inaction the same result may follow. Thus, the 
following case was furnished by a subject affected with a very 
mild form of blennorrhagia, which became transferred from the 
urethra to the bladder, and this, too, while the patient observed 
complete repose, submitted to regimen, and guarded against ex- 
cesses of every kind, as well as the sudden changes of tempera- 
ture. I shall confine myself to a description of this case, as the 
cystitis, which most commonly arises from the gradual extension 
of the urethral inflammation, is analagous to all the cases of cys- 
titis which have been described in standard works. This case, 
moreover, is especially interesting in a practical point of view ; it 
is a remarkable example of success obtained by cauterizing the 
perineum. 

Case 4th. — Gr. set. 30, quarryman by occupation from the age 
of fifteen ; born at Montigny, but resided in Paris since six years 
old.; of high stature, strong limbs, ruddy complexion, hair and 
beard black and copious, of vigorous aspect. Gr. always enjoyed 
good health ; has been accustomed to drink much wine, but little 



BLENNORRHAGIC CYSTITIS. 147 

brandy ; was never addicted to masturbation ; never bad sexual 
intercourse before the age of twenty, and until 1840 had always 
indulged in it with great moderation ; during the past two years, 
however, he has carried it to excess. His labor was difficult, 
though he never descended into the mines. About the 20th of 
May, 1842, the patient, who had never suffered from the venereal 
disease, had connection with a prostitute, the result of which was 
a discharge. At the commencement the pain in urinating was 
very severe ; the matter discharged was of a whitish color, not 
thick, but abundant in quantity. He suffered from frequent and 
painful erections. Gr. did not submit to any treatment ; he stated 
that he had followed regimen alone, but continued to work until 
the 26th of May. Then the pain became more severe, and the 
glans and prepuce swollen. The patient confined himself to his 
bed until the 2d of June. On the 3d he came from Montrogue to 
Paris, and obtained a bed in my service. 

At this time the prepuce was swollen, red cedematous, and 
crossed the glans, which was itself enlarged ; the whole covering 
of the penis was infiltrated with serum. A whitish matter was 
discharged through the opening of the prepuce, and the pain was 
very severe. Ordered local emollient baths, to be prolonged and 
repeated three times a day ; emollient injections between the pre- 
puce and glans ; rest in bed ; an allowance of food, and general 
bathing. 

Under the influence of these means the external symptoms 
rapidly improved. On the 15th June there remained but slight 
oedema at the inferior part of the prepuce, which yielded in the 
course of a few days to compression made with narrow straps of 
diachylon plaster. 

June 25th. — There exists only an urethral discharge, thin, and 
small in quantity ; pain however whilst urinating, and after urin- 
ating is very severe. Patient refers the maximum of pain towards 
the meatus urinarius. He observes the same regimen. 

30th. — Patient has been allowed three portions of food, but the 
pains have increased, and a little blood is voided with the urine, 
which in other respects is quite limpid ; he urinates six or seven 
times in the twenty -four hours. No change in the discharge ; two 
portions ; confinement in bed ; three purgations to remove an ob- 
stinate constipation, to which, moreover, the patient is accus- 
tomed. 

July 6th. — Discharge the same, and at each attempt to urinate 
little clots of blood are passed ; the urine is still mixed with some 
shreds of blood ; the pain is the same whilst voiding urine and 
for some time after the act, when the patient becomes tranquil. 

14th. — Urine is no longer mixed with blood ; the discharge is 
much less, but the patient is compelled to urinate more frequently, 
being warned by a severe pain the perineum. This pain is not 
increased by the passage of the urine, but it lasts for a quarter of 
an hour after the water has passed. One portion ; two of milk ; 
whey for drink, and patient to remain quiet. 

20th. — For several days the patient has urinated almost eyeiy 



\4:S VIDAL Otf VENEKEAL DISEASES. 

hour. When the desire is felt he experiences a sharp, overwhelm- 
ing pain behind the penis ; if the desire be resisted, the pain ex 
tends to both groins, and compels him to urinate. During the act 
it is felt at the root of the penis. Another pain exists in the hy- 
pogastric region, at a point which corresponds to the situation of 
the bladder. The discharge is very slight ; the quantity of urine 
is not increased. The urine, which for eight days has been per- 
fectly limpid, now deposits a thick layer of greenish mucus, resem- 
bling jelly, thready, and adhering to the bottom of the vessel. 
The pains are very severe, and the disposition to urinate most 
frequent towards evening. At the same time there is some febrile 
excitement. Ordered to continue regimen ; twenty -five leeches to 
the perineum, and the bath. 

28th. — The leeches have been applied the second time. The 
pains are greatly diminished, and the patient has not urinated 
more than fifteen times since yesterday morning. Last evening 
did not feel the lassitude and febrile excitement which had existed 
for some days, but the deposits in the urine are still the same. 
Patient still suffers in the hypogastric region. Ordered inspissated 
turpentine one drachm ; continue the baths. 

Aug. 3d.' — The discharge is very slight, almost without color ; 
deposit in urine less abundant, less viscous, and not of so green a 
color. The pains continue severe ; patient urinates fifteen times 
in the twenty -four hours ; urine slightly increased in quantity. 
Dose of turpentine increased to two drachms ; perineum cauterized 
with Vienna paste ; milk- whey ; two portions. 

12th. — The eschar has separated, and a pea is inserted. Tur- 
pentine to be continued in two-drachm doses ; urine becomes more 
and more transparent, only a slight deposit of a whitish color re- 
maining in the bottom of the vessel ; this deposit is but slightly 
adhesive, and the color of the urine is changed to citron. The 
pain which warns the patient of the necessity for urinating is still 
very severe behind the penis ; it continues during the passage of 
the urine, but ceases immediately after it is evacuated. Patient 
urinates twelve times in the twenty -four hours ; he asks for food ; 
double allowance ; three times the quantity of milk ; continue the 
turpentine. 

25th. — The discharge has ceased, but from time to time there is 
a very slight weeping. The urine is voided without pain, and 
has been limpid for some days. The dispositions to urinate are 
less frequent, and manifest themselves by less urgent desires ; be- 
' sides, it is now at the root of the scrotum, and not behind the 
pubes nor in the groins. Continue the cautery ; omit the turpen- 
tine ; treble the allowance. 

Sept. 3d. — Patient has eaten four times, and sits up every day. 
He urinates not more than five or six times in twenty-four hours, 
and this without difficulty or pain. He can resist for hours the 
disposition to void his urine, without inconvenience. Urine is 
clear ; and there is no discharge from the urethra. The improve- 
ment is constantly progressive. 

10th. G. is perfectly cured, and obtains his discharge. 



BLEOTORRHAGIC NEPHRITIS. 149 

I recommend to practitioners the application of the cautery to 
the perineum, a plan of treatment which I often adopt in obstinate 
cases of cystitis. Sometimes I substitute for it the seton, which I 
pass through a fold of the skin in the same region. For example, 
in Ward No. 11 of my service, was a patient troubled with an 
affection of the bladder, which had resisted every possible indirect 
means, and two applications of the cautery, but which yielded to a 
seton inserted in the perineum. 



BLENNORRHAGIC NEPHRITIS. 

The attention of the profession begins to be seriously directed 
to the study of inflammations of the kidneys, in their connection 
with chronic affections of the urethra, the prostate, and bladder. 
These cases of nephritis moreover are very frequent, for most of 
the diseases of the genito-urinary apparatus which precede that of 
the kidneys, being attended with more or less complete retention 
of urine, it is reasonable to suppose that the too prolonged sojourn 
of the urine should become a new cause of aggravating and of 
extending the inflammation already existing, which passes from 
the bladder to the ureters, and is thence often transmitted to the 
kidneys. M. Eayer reports a case,* showing the existence of in- 
flammation in its most extensive form. The patient was first 
attacked with blennorrhagia, then followed stricture with infiltra- 
tion of urine, and abscesses ; to these succeeded pains in the hy- 
pogastric regions, about the kidneys, frequent dispositions to uri- 
nate, purulent urine, numbness in the lower extremities. Finally, 
the death of the patient afforded an opportunity of establishing 
the anatomical lesions of every part of the genito-urinary appara- 
tus. But when these lesions occurred sloAvly, as we find recorded 
in the books, as M. Eayer remarks, it may be suspected that some 
other inflammation' is added to the effects of the blennorrhagic in- 
flammation, which, besides, for some time, has singularly changed 
its characters. For example, in the case reported by M. Eayer, 
this practitioner observes, that the symptoms of nephritis appeared 
seven years after the blennorrhagia, and the nephritis was calcu- 
lous. M. Eayer has recorded no case which scientifically estab- 
lishes what I call blennorrhagic nephritis ; in other words, that 
inflammation which in its nature may be compared to orchitis. 

Benjamin Bell, in his extensive treatise on Gonorrhoea Virulenta, 
is very brief on the connections of this affection with nephritis. 
He observes in one passage :f " The kidneys become sometimes 
affected through nervous sympathy, or in consequence of the 
extension of inflammation along the ureters." We have, then, 
two kinds of blennorrhagic nephritis, which may be compared to 
blennorrhagic orchitis. This opinion of Benjamin Bell is worthy 
of note, as it has some bearing on the case reported in the LXIIcl. 
letter of Morgagni. It is that of a chevalier, a?t. <±6, who had 

* Traite des Maladies des Reins, t. iii. 
f Vol. i., p. 41. 



150 VIDAL OK VENEKEAL DISEASES. 

three attacks of blennorrhagia, followed by accidents, tbe seat of 
which was always referred to the bladder, which organ was sup* 
posed to be seriously affected; now behold what the autopsy 
revealed : " The kidneys were smaller than natural ; their form 
was extraordinary; and presented at various points externally 
several protuberances. The dissection of these brought into view 
a sanious humor, which had an open passage to the calices. But 
in the bladder, which, by several scientific men, was unanimously 
supposed to be the seat of the principal disease, nothing of conse- 
quence was found, except a slight erosion about the orifices of the 
ureters. 

In this case, the blennorrhagic inflammation had leaped over 
the bladder and seized upon the kidney, which was found in a 
state of suppuration. In reading this case, we cannot but regret 
the absence of details, in reference to the condition of the urethra 
and the prostate. 

The connections of blennorrhagia with nephritis are very remote ; 
in the reports which I have been able to find in different works, 
a long time has always intervened between the two affections 
There have always been several attacks of blennorrhagia, and the 
appearance of the nephritis is of a date very distant from that of 
the last blennorrhagia, which is considered as its cause. I insert 
in this place the particulars of a case which occurred in my service, 
and which establishes, in a manner much more precise, the inti- 
macy of the relations existing between blennorrhagia and nephritis. 

Case. — P. Theophile, set. 23, painter, born at St. Brieux ; pale 
complexion, black hair, middling height, statue lean, limbs small, 
muscles imperfectly developed, health generally good. P., how- 
ever, was easily fatigued. Having lived in Paris for the last five 
years, during this time was guilty of excesses with females, not 
so much for the last two as the three preceding years. In other 
respects, his conduct had been good. At the age of 17, he con- 
tracted a blennorrhagia from his first connection with a female. 
From the commencement he suffered severe pain in urinating, the 
discharge was of a greenish color, and abundant in quantity, and 
there was redness about the mouth of the urethra. He adopted a 
severe regimen, and made use of tisanes for a month ; then he 
took Chopart's potion, and the discharge entirely ceased. One 
month afterwards, P. contracted a new discharge, which was less 
painful than the preceding, and which was cured nearly in the 
same manner. At this period he came to Paris, where he resided 
for two years without being affected by the venereal disease. 

About two years since he had a third attack of blennorrhagia. 
The latter was not of an acute form ; indeed, there was but trifling 
pain, no redness, the discharge of a white color, rather thin, and 
small in quantity. The patient submitted at first to regimen, 
without adopting any active treatment. After some weeks, there 
was nothing but a weeping from the urethra, which appeared prin- 
cipally in the morning, and which increased at intervals, attended 
with an itching sensation in the urethra. P. resumed his habits, 
still had connection with females, &c, &c. About the 10th of Sep- 



BLENNORRHAGIC PHRENITIS. 151 

teraber last, matters being in this condition, P. experienced pain 
in urinating, and still greater pain during an erection. The dis- 
charge became thicker and more abundant. Was this a new 
blennorrhagia that the patient had contracted, or was it an aggra- 
vation of the old attack? At any rate, it lasted for twenty 
days, with the same characters as at first, when the patient, for a 
whole night, indulged excessively in wine and brandy. The next 
day the discharge became thicker, of a greenish color, and slightly 
tinged with blood ; the emission of urine was accompanied with a 
smarting sensation towards the glans. Soon a more acute pain 
was felt behind the pubis, which was exasperated by the accumu- 
lation of urine, and the efforts to expel it. The disposition to 
urinate was not more frequent than usual, but the desire was more 
urgent ; sleep was good, and uninterrupted during the night. He 
remained in this condition for about two weeks. P. continued the 
use of the baths ; he pretended to observe a proper regimen, yet 
he ate large quantities. He took long walks in the evening, made 
use of copaiva, and purged himself repeatedly. The pain behind 
the root of the penis rapidly diminished, the discharge completely 
ceased, and he had only a slight and shifting pain in the pelvis, 
which was not increased in urinating. 

During the night of the 15th Oct. he was disturbed by chills, 
and was soon seized with a sharp, fixed, deep-seated and lancinat- 
ing pain, on a level with the left kidney. He was restless during 
the whole night, but was somewhat better in the morning. The 
pain became greatly aggravated every evening ; it was always re- 
ferred to the situation of the left kidney, and was perfectly limited 
to this region. His nights continued to become worse and worse ; 
the pain which increased daily, became so severe as to extort cries 
from the patient. His only relief was obtained by lying on the 
side affected, and by taking large doses of the syrup of opium. 
He remained in bed, and took only a little broth, for, to use his 
own language, " I had fever." A physician in town recommended 
the application of a cataplasm to the painful part, and expressed 
the opinion that he would soon be relieved. 

P. came under my care, Oct. 27th, 1842. During the whole day 
he was affected with tremors, which he attributed to the change 
from his hot chamber to a colder temperature. Pain very severe 
in the region of the left kidney, fixed and confined to this space. 
Urine copious, voided naturally and without pain, and at healthy 
intervals it is of a high color, slightly bloody, and deposits a thick, 
whitish purulent layer, which does not adhere to the sides of the 
vessel. No pain in the hypogastric region ; a feeling of weight 
and uneasiness along the course of the spermatic cord and the left 
testicle. Ordered four cups to be applied to the painful region ; 
milk- whey for drink, and a milk nourishment. 

Oct. 31st. The cups drew considerable blood ; the fever is 
somewhat abated, the tremors and agitation has disappeared, pain 
is less, bat the urine remains purulent. Deposit large, but hypo- 
gastric region free from pain. Appetite not impaired. Apply 
twenty leeches to the anus ; continue the whey ; milk nourishment. 



152 VTDAL ON VENEREAL DISEASES. 

Nov. 1st. General condition improved ; the fever and nervous 
irritation have ceased. Urine always voided at natural intervals ; 
renal pain still continues. Apply three cups to the painful part. 

3d. Not only the lancinating but the fixed pain, which existed 
before the application of the last cups, has disappeared. Urine is 
still a little cloudy, but the deposit has nearly ceased. 

8th. Continues to improve ; no pain in kidney ; no fever. The 
discharge has not reappeared, and there is no pain in the region 
of the bladder ; general condition perfect. Allow a little chicken. 

11th. Pain has not returned ; pulse and appetite are good ; no 
agitation ; urine limpid ; patient convalescent. 

I repeat that this case is remarkable, as showing the intimate 
connexion between blennorrhagia and nephritis. The reader will 
not fail to note the following circumstances : 1st. The extraordi- 
nary quantity of purulent matter found at the bottom of the ves- 
sel. 2. The absence of pain in the hypogastric region. 3d. The 
power which the patient had of retaining his urine, the same as in 
perfect health. The two last-named circumstances go to prove 
that the bladder remained unaffected during the existence of the 
nephritis, for when the cavity of this organ is inflamed the urine 
cannot be long retained, and great expulsive efforts are made to 
discharge it ; thence the continual tenesmus ; again, pain is felt in 
the region of the bladder. In this patient none of these symptoms 
were experienced. Was it owing to a sudden metastasis of the 
blennorrhagia ? Had it, as it were, leaped over the bladder, as 
we see it pass from one testicle to the other, without involving 
the intermediate points? It is true that after the night of de- 
bauchery already mentioned, there had been a severe exasperation 
of the urethritis and the cystitis. But during the development 
of the nephritis, the bladder remained unaffected, and yet the 
urine was decidedly purulent. The patient suffered no vesical 
tenesmus ; the disposition to urinate was no more frequent than in 
a state of health. To many of my readers the question may sug- 
gest itself whether the more serious inflammation may not have 
obscured the lesser one, and the cystitis been thus masked by the 
nephritis, thus affording some grounds for the observation made 
by Valsalva after the autopsy of Chevalier detailed in the letter of 
Morgagni, to which we have already alluded. " Valsalva thought 
that this dissection was calculated to make us cautious when called 
to treat affections which are referred to the urinary organs, be- 
cause very frequently, even when we exercise the greatest care, 
we may commit an error in diagnosis as was the fact in this 
case."* Thus, in the instance to which Valsalva refers, they ex- 
pected to find traces of a cystitis, but they were wanting. In my 
patient I might indeed have committed the opposite error. That 
which should console me is the success which I attribute to the 
two applications of the cups in the region of the kidney, the part 
supposed to be affected, and to the use of leeches in large numbers 
about the anus. These local depletions were quite copious, and 



* Letter, xlii. § 3. 






BLENNORRHAGIC OPHTHALMIA. 153 

accorded with my wishes, notwithstanding the apparent debility 
of the subject, his pallid countenance and slender figure. Practi- 
tioners know that in severe inflammations of the urinary organs, 
the abstraction of blood is indicated, and the more deeply the or- 
gan affected is situated, the more frequent and copious should this 
depletion be made. Whilst writing this, a patient is admitted un- 
der my care, who had been treated by my predecessor, M. Cul- 
lerier. This patient was affected with a blennorrhagia, and M. 
Cullerier gave him three doses of powdered cubebs which he took 
at once. The discharge was suddenly suppressed, and he suffered 
acute pain in the region of the kidneys. The numerous cicatrices 
of incisions made by the scarifier, satisfies me that the above 
symptoms were followed by important morbid phenomena, and 
for which M. Cullerier had the cups applied.* 



BLENNORRHAGIC OPHTHALMIA. 

This form of ophthalmia, one of the most serious accidents of 
blennorrhagia, which is so frequent, and which gives rise to theoret- 
ical and practical questions of the highest importance, is neverthe- 
less passed over in silence by Hunter ! 

Causes. — It necessarily depends on a blennorrhagia. Its devel- 
opment has been differently explained : metastasis, inoculation, 
general infection and sympathy have all in turn been accused. 
Saint- Yves was among the first to defend the doctrine of a metas- 
tasis, a doctrine which emanated from the absolute reign of humor- 
ism. Under that of exclusive solidism this doctrine was com- 
pletely abandoned. This was an error. Sanson, who denied the 
doctrine of a metastasis, is said to have frequently observed this 
affection, and the urethral discharge was never suppressed when 
the eye became involved. Further still, this ophthalmia has been 
observed in subjects who never had a blennorrhagia, but who had 
been brought in contact with persons so affected ; they washed 
their eyes with a sponge wet with the blennorrhagic discharge, or 
they had used a collyrium of the urine of persons affected with the 
disease. These facts favor the idea of a contagion. But facts do 
not warrant us in asserting that this ophthalmia is always thus pro- 
duced. For my own part, without denying the doctrine of conta- 
gion, I am a decided advocate of that of metastasis. The follow- 
ing are my reasons: — 1st. In almost all the cases observed in my 
wards at the Hopiial du Midi, this ophthalmia has co-existed with a 
blennorrhagic arthritis : now, this, arthritis was certainly not 
caused by contagion, but, without doubt, by a transfer of the irri- 
tation or humor. Why should this not be the case in blennorrha- 
gic ophthalmia ? 2d. The number of these affections bears a 
very small proportion relatively to the number of cases of blen- 
norrhagia, and of individuals who are careless of their persons. 
3d. Besides, when the fingers are brought into contact with the 

* Extrait des Annales de la Chirurgie, t. vi. 



154 VTDAL ON VENEREAL DISEASES. 

eyes, the latter are covered by the eyelids, and the conjunctiva is 
not directly touched ; for, to do this, it would be necessary to 
depress the lower eye-lid, as the lids close instinctively, and we 
know that it is on the internal surface of the lids that this form of 
ophthalmia commences — in other words, at a point least liable 
to be contaminated by contact with the fingers. 4th. This 
ophthalmia occurs during the decline of a blennorrhagia, at a 
period of the disease when the contagious properties of the muco- 
pus is diminished. 5th. Why is it that the discharge of blennor- 
rhagia inoculates the eyes, whilst the pus from a chancre never 
inoculates ? Indeed, patients may be daily seen at the Hopital du 
Midi with chancres in full suppuration, and buboes, the discharges 
of which soil all their garments, who are very negligent in their 
persons, and constantly applying their hands to their face, and yet 
they have never contracted purulent ophthalmia, even when the 
pus from the chancre on the penis would inoculate the smallest 
leech-bite, the scrotum, the perineum, and the unabraded skin. 
6th. The patients whom I have seen affected with blennorrhagic 
ophthalmia were precisely those who best understood the import- 
ance of care and cleanliness under the circumstances in which they 
were placed. I will even add, that some of these patients were 
suffering from a second attack of blennorrhagia, which, like the 
first, was followed by a purulent ophthalmia. They were, at the 
time, duly warned of the danger of applying their fingers to their 
eyes, and yet they became inoculated ! 

The doctrine which attributes an important part in the produc- 
tion of these ophthalmias to sympathy, has found many advocates 
among the solidists. Sanson, without being absolute, adopted this 
opinion, and presented, in their strongest light, the arguments and 
facts in its support. He maintained, that the sympathy between 
the mucous membrane of the urethra and that of the eye, is proved 
by the feeling of smarting in the latter organ, and the impaired 
vision which follows every protracted irritation of the genital 
organs. "It is known, strictly speaking," says Sanson, "that a 
current of cold air, under these circumstances, coming in contact 
with the conjunctiva, may determine an irritation, which, in a 
sound individual, would become purely catarrhal, and which, in a 
person affected with blennorrhagia, may take a more serious char- 
acter. However," continues this surgeon, with much reason, "this 
explanation does not fully satisfy the mind. All that is positively 
known on this subject, is, that in the individuals in question, con- 
junctivitis may assume certain forms which it does not in others." 

Sanson's opinion may be reconciled with that to which I am 
myself inclined. I believe that, in the majority of cases, the pur- 
ulent ophthalmia, which, after an attack of blennorrhagia, follows a 
certain course, is an accident which is analagous to the arthritis 
which occurs under the same circumstances. The blennorrhagic 
virus is transported by the blood or otherwise, and it is not to the 
topical action of the muco-pus of the urethra that this unfortunate 
occurrence, called blennorrhagic ophthalmia, is to be attributed. 
However, that atmospheric influences should be taken into consid- 



BLENNORRHAGIC OPHTHALMIA. 155 

eration, tliat the patient would have escaped an attack of ophthal- 
mia if he had not been exposed to a current of cold air, is possi- 
ble, as it is probable that of those affected with blennorrhagic 
arthritis, some would not have suffered had they guarded against 
atmospheric changes. This influence of a general cause allies the 
blennorrhagic to the Egyptian ophthalmia, to that of infants, in 
the production of which atmospheric influences exert so important 
a part. But it should likewise be known, that blennorrhagic 
ophthalmia sometimes occurs under hygienic circumstances most 
favorable to the healthy exercise of the functions of the eye, where 
we are unable to trace the slightest cause, as is sometimes the 
case with blennorrhagic orchitis and arthritis. 

Symptoms. — The redness is here more decided than in any other 
variety of ophthalmia ; it is a scarlet of the deepest dye, from 
which it changes to a brownish red. The tumefaction also attains 
its maximum. Chemosis exists in its worst form ; the excessively 
tergid mucous lining of the eye-lids constitutes a hernia, and there 
is a kind of acute ectropion, which separates the celiary margins 
of the lids. According to M. Desmarres, the hernia of the lining 
membrane is sometimes strangulated by the orbicularis palpebra- 
rum ; this skillful oculist then compares it to the rectum stran- 
gulated by the sphincter ani. The swelling involves even the skin 
of the eye-lids ; which are so tumefied as to give to the orbit the 
aspect which is pathognomonic to those practitioners who are 
familiar with this form of ophthalmia. The superior falls over the 
inferior lid, and the two are, as it were, imbricated. The dis- 
charge, always copious in the specific forms of ophthalmia, is still 
more abundant in this. It is said that it comes principally from 
the upper lid ; it is, indeed, especially along its free border, that 
we see the secretion escape. This fact authorizes us in believing 
that the Meibomian glands play an important part in its produc- 
tion. This discharge is at first bloody and thin, it afterwards 
becomes thick and greenish, and perfectly resembles that of blen- 
norrhagia ; it stains the linen in the same manner ; at last it becomes 
white and of a creamy consistence ; and its contact excoriates the 
skin of the cheeks. The pain is very severe, extensive, and burn- 
ing, it is felt on the forehead when it is dull and heavy. It is 
throbbing, and extends to the temporal and occipital regions. 

"With such a chemosis, and so severe an inflammation of the eye, 
we should naturally expect that the retina nrast suffer ; and there 
would be a well-marked photophobia ; it is, indeed, very decided, 
but as a general rule it soon ceases ; it is always a bad omen when 
it disappears very suddenly, for the effusions have taken place in 
the interior of the eye, which have impaired the sensibility of the 
retina. 

We find that in these cases, all the physical and physiological, 
the objective and subjective, symptoms of ophthalmia are mani- 
fested in their highest degree. Such is sometimes the case with 
the general reaction ; thus, the patient is greatly agitated ; there is 
sleeplessness, delirium and stupor; the pulse is full, the tongue 
furred ; everything in fine is indicative of cerebral disturbance and 



156 YIDAL ON VENEREAL DISEASES. 

of real danger. However, I have observed several cases of this 
form of ophthalmia, where the eyes have been lost, and yet there 
was no general disturbance of the system. 

Progress. — It may be of frightful rapidity. Here a timid practi- 
tioner, slow in deliberation, and slow in execution, will often find 
himself taken unawares, for six hours may suffi.ce to prepare the 
way for the destruction of the eye, and to seriously compromise 
the whole system. Sometimes the disease is seen to progress more 
slowly, but it is not less serious ; thus, instead of destroying the 
organ in a few hours it may occupy ten or twelve days. 

In some instances its progress is quite insidious ; for example, 
it may commence in a very mild manner, and preserve this charac- 
ter for • some days ; then, suddenly it reaches its maximum of 
intensity, and the eye will inevitably be lost. It may happen 
also, that the ophthalmia appears in this moderate form, and the 
eye, though abandoned to itself, may escape uninjured ; yet it may 
show itself suddenly in the other eye and this be lost forever. 

Terminations. — A complete, entire resolution is rare. The result 
is often a destruction of the eye. It is true, that in a great num- 
ber of cases, but one eye is destroyed. It is evacuated in several 
different manners ; sometimes it is by a sloughing of the cornea, 
which is said to arise from the strangulation, from the inflamma- 
tion which has interrupted the circulation between the conjunctiva 
and the transparent cornea; or, the eye may be discharged by 
ulcerations, which commence on the surface of the cornea, become 
excavated, and extended thus, giving vent to the humors of the 
eye. One of the most serious affections following purulent oph- 
thalmia is staphyloma. An hypopion, amaurosis, cataract, ectro- 
pion, and prolapse of the iris, may all follow this terrible ophthalmia. 
I have seen vegetations also after this disease ; they were attached 
to the conjunctiva precisely in the same manner as those which are 
observed on the prepuce. 

Prognosis. — This is grave, when the ophthalmia has not been 
vigorously attacked in the commencement ; even then we should 
always be guarded in the opinion we express respecting the result 
of the disease. 

Treatment. — Here general and local treatment, direct and indirect 
antiphlogistics, cauterization, all, so to speak, should be at once 
employed, the same day, if at its onset the disease puts on a serious 
aspect. Thus, I have commenced by phlebotomy in the foot, or, 
if the saphena does not bleed well, I take blood from the arm ; I 
apply leeches continually to the temples, and then I administer an 
emeto-cathartic. Beware how time is lost in using liquid or semi- 
liquid collyriums, or insufflations of calomel and sugar ; on all 
these means, invariably unsuccessful, no reliance is longer placed. 
The cures attributed to their employment are very questionable. 
Dupuytren, who so much lauded and used these insufflations, never 
obtained the least success. Those who visited the Hotel Dieu 
during the lifetime of this celebrated surgeon, know what import- 
ance to attach to the practice under consideration. Further, we 
need but peruse the cases detailed by Sanson in his article on 



BLENNORRHAGIC OPHTHALMIA. 157 

Ophthalmia. This surgeon, having unsuccessfully tried all the 
methods of treatment, resolved on resorting to a violent, but accord- 
ing to him, efficacious plan. He destroyed the part, the morbid 
secretion of which produces such disastrous effects upon the cornea. 
"I excised all the ocular conjunctiva and cauterized with nitrate 
of silver all the palpebral conjunctiva which was too adherent to 
be removed. I am so convinced of the efficacy of this eradication 
over every other method of treatment, that should I meet with a 
case in which the swelling of the lids was such as to render their 
separation impossible, I would not hesitate to divide the external 
commissure to facilitate their separation and the application of this 
method." 

This excision being sometimes impracticable without the debride- 
ment of which Sanson speaks, and this operation be attended with 
real inconveniences, cauterization, with the nitrate of silver, has 
been employed. A blunt-ended cylinder of this salt has been 
carried around the circumference of the cornea, with the precaution 
of avoiding the centre of this membrane, lest it be disorganized. 
The caustic will also act upon the lining membrane of the lids, and 
especially the superior, which is the greatest source of the discharge. 
The whole interior of the lids then assumes a dark gray tint, a 
large quantity of pure blood is immediately lost, and a dirty red- 
dish-brown water is discharged in a deluge. A smarting, burning 
sensation is immediately felt ; the suffering is so severe that the 
patient would fall in frightful spasms, if immediate recourse were 
not had to the constant affusion of cold water between the lids and 
over the whole fronto-palpebral region. 

After the excision and cauterization, M. Rognett gives tartar- 
emetic in large doses (twelve grs. to six oz. of water) ; and, ac- 
cording to his reports, an amendment always takes place. The 
next day he substitutes for the application of simple water that .of 
d'eau blanche strongly charged (one oz. acet. plumb, to four oz. of 
water). It is seldom that it is necessary to repeat the cauteriza- 
tion. Of course every particular observed in a decided case of 
conjunctivitis must also be regarded in that under consideration. 
If the patient cannot bear the tartar emetic in large doses, M. Rog- 
netta employs some other contra-stimulant, such as the extract of 
belladonna, from six to eight grs. in the day ; a pill containing one 
gr. every two hours, with a small quantity (three grs.) of calomel ; 
the acetate of lead, from twenty to thirty grs. in the day ; a pill of 
two grs. every two hours ; the extract of hyoscyamus in quantities 
from fifteen to twenty grs. in the day, &c. All these remedies in 
large doses act like tartar emetic ; in other words, they diminish ex- 
citement ; and, what is extraordinary, these enormous doses, which 
in a state of health would poison the person taking them in the 
case of a grave inflammatory affection, produce only the same 
effects as would the copious abstraction of blood. Those who are 
acquainted with the valuable experiments of Rasori and Gria- 
comini on the true effects of these remedies, will not be surprised 
at the formulas above mentioned. 

Tyrrel, believing that the sloughing of the cornea in cases of 



158 VTDAL ON VENEREAL DISEASES. 

purulent opthalmia, arises from the strangulation of this membrane, 
has proposed a kind of debridement of the conjunctiva which forms 
the chemosis. Adopting the principal of multiplied debridements, 
he incises the conjunctiva around the cornea, from which point he 
carries his incisions outward so as to make four radiating wounds, 
directly in the spaces intermediate to the recti muscles. Accord- 
ing to Tyrrel, we thus avoid the principle nutrient vessels of the 
cornea. This multiplied incision is to be preferred to general ex- 
cision, by which we remove all of these vessels and endanger the 
vitality of the cornea. Tyrrel pretends to have cured all his pa- 
tients by this operation. I believe that in the majority of cases, 
it would be exceedingly difficult to make these incisions as he 
directs, and especially to make them precisely in the spaces in- 
dicated. 

For my own part, I at first resort to one or more general ab- 
stractions of blood, with local depletion, according to the consti- 
tution and age of the patient ; immediately afterwards I admin- 
ister an emetic, and then cauterize the ocular conjunctiva, the 
whole being done the same day. On the following, prescribe a 
cathartic, which is to be repeated every second day. 



BLEKNOERHAGIC ARTHRITIS. 

During the progress of blennorrhagia, it is quite common to 
observe this accident, and yet, up to the time of Swediaur, authors 
passed it in silence. Swediaur himself does not devote more than 
a page and a half to its consideration. It is probable that this 
affection was at that time regarded as ordinary rheumatism, which 
was merely coincident with the blennorrhagia. But as it has been 
proved that certain patients never suffer except when affected 
with blennorrhagia, the connection between the two diseases has 
been . established, and a blem^orrhagic arthritis or rheumatism has 
been admitted and described. 

Causes. — A blennorrhagic urethritis is regarded as the specific 
cause of the disease in question. Doctors Jarjavay and Foucart 
admit that balano-posthitis may, like urethritis, give rise to it, but 
this must be an exception to the general rule. 

Men are more frequently affected than women. Almost all 
the subjects which I have treated have been emaciated, pale and 
debilitated, and about thirty years of age ; several have had re- 
lapses on a second attack of blennorrhagia. 

Cold and violent exercise may exert an influence in the pro- 
duction of this disease ; and they may then be regarded as occa- 
sional causes. 

Great importance has been attached to the suppression of the 
discharge, and then its development has been attributed to a me- 
tastasis. The direct and indirect anti-blennorrhagics have then 
been accused. But the discharge sometimes ceases without any 
treatment, ^.nd yet this arthritis has been seen to occur during the 
mildest treatment, the most perfect rest, and while the patient is 



BLEOTORRHAGIC ARTHRITIS. 159 

observing a strict hygeine. I will add that the discharge is not 
always suppressed when the arthritis appears ; it is often slight, 
for the reason that the articular affection is generally observed 
during the decline of a blennorrhagia, when it has already existed 
several weeks or months. It never occurs during the first week 
of the latter disease. On this account, however, we should not 
deny the influence of the arthritis on the quantity of the discharge, 
nor a metastasis, for there can be no doubt, that after the arthritis 
is cured, the discharge often becomes more abundant than during 
the existence of the articular disease. As regards the metastasis, 
without wishing to enter here into the discussions to which this 
doctrine has given rise, I will remark, that by this term I do not 
understand a displacement, a conveyance of the humor of a blen- 
norrhagia itself but the displacement of the cause of this humor. 
Thus, in the arthritis in question, it is not the muco-pus from the 
urethra which is carried to the articulations, but the cause which 
produces it, the blennorrhagic cause which invades this same ar- 
ticulation. 

Dr. Foucart, who has written an excellent work on blennor- 
rhagic arthritis, has given the following summary of propositions 
on the connection of the arthritis with the discharge : 

" 1. When the discharge has been suppressed before the ap- 
pearance of the arthritis, the latter then depends either on a me- 
tastasis, or the cause which gave rise to the suppression. 

2. When the discharge still continues, and the development of 
the rheumatism is determined by an occasional appreciable cause ; 
such as cold, contusions, excessive fatigue, the blennorrhagic dis- 
charge then acts only as a predisposing cause. 

3. When, in fine, the discharge exists, and there is no other ap- 
preciable determining cause of the arthritis than the blennor- 
rhagia. 

4. Sometimes, in the two cases last mentioned, the suppression 
of the discharge is consecutive to the development of the rheuma- 
tism, the latter being very severe. It does not then depend upon 
a metastasis, but simply a revulsion produced by a more intense 
inflammation in the part secondarily, than in that which is prima- 
rily affected.* 

Seat. — Swediaur noticed the fact that the knee is the articulation 
most frequently affected. True, he mentions the calcaneum, by 
which term he probably intended the ankle joint. (I know not 
why M. Gilbert persists in using this term.) Generally it is really the 
knee joint, and a single knee, that is affected. M. I. Cloquet thinks 
that in women, he has more frequently observed the disease in the 
coxo-femoral articulation, an opinion which has not been corrobo- 
rated by any other author. Further, we find this form of arthritis 
involving all the joints, several being simultaneously or consecu- 
tively affected. There is in my wards at the Hopital du Jlich] a 
young man affected with an arthritis in the articulation of the first 
phalanx of the index finger with the corresponding metacarpal 

* Foucart, Gazette des Hopitaux, 1846, p. 192. 



150 VIDAL ON VENEREAL DISEASES. 

bone, and very near to this patient, is another in which the disease 
is seated in the wristjoint. M. Bejmard, surgeon in chief of the 
Marine, has treated a student in whom all the joints, both of the 
upper and lower extremities, were successively involved.* But 
when several of the joints are attacked, there is always one in par- 
ticular which remains the longest affected, and which becomes the 
seat of serious accidents, leading sometimes to other changes, by 
which the arthritis becomes transformed into a white swelling. 
Sometimes it happens even that only a pain more or less deeply seated 
is felt in the other articulations, the movements of which are some- 
times impaired. 

Symptoms. — Generally the pain and swelling are the first symp- 
toms which manifest themselves. Sometimes, however, these are 
preceded by chills and fever, and by vague wandering pains. The 
pain is less severe than in the other varieties of acute arthritis, such 
as the ordinary rheumatic, the traumatic, or that caused by the 
penetration of a tubercle in the articulation. [Some two years 
since we treated a patient affected with blennorrhagic rheumatism 
in the ankle joint, and the pain was more severe than ever occurred 
in any form of articular disease which has come under our obser- 
vation. — Gr. C. B.] The movements of the joint are impeded, or 
rendered even impossible ; like pressure with the fingers motion 
increases the pain, but to a less extent than in the form of arthritis 
which I shall mention. The swelling is sudden and sometimes 
considerable. We may perceive that this tumefaction does not de- 
pend upon an enlargement of the bone, nor a swelling of the soft 
parts surrounding it. It arises from an effusion within the joint, 
an hydarthrosis, which may easily be detected, when the knee is 
the joint affected. The patella, indeed, is raised and separated 
from the femur and the tibia ; it is movable and as it were float- 
ing. On the sides of this little bone, instead of two depressions, 
are two more or less marked elevations. If we press upon one, 
we depress it, but raise the other ; we may press the fluid from 
one to the other side, we may in fine produce fluctuation. 

The color of the skin remains generally unchanged, and its 
temperature is natural. The absence of the external characters of 
inflammation, at the outset of the disease, is a fact so constant, that 
when the opposite occurs, we should carefully examine to see if 
indeed it is a blennorrhagic arthritis, or if some comjDhcation has 
not given an acute character to an affection at first subacute. At 
a later period, as the articular affection progresses, it is character- 
ized by really inflammatory phenomena. The swelling is more 
tense, the skin hotter and more highly colored, and the vascularity 
around the joint is increased as in acute rheumatism. The urethral 
discharge then ordinarily undergoes a marked diminution, a cir- 
cumstance which does not occur, when the disease remains in a 
state of hydarthrosis. 

As we generally find that the blennorrhagic arthritis commences 
without any previous fever, we also frequently observe apyrexia 

* Traite pratique des maladies veneriennes, p. 204. 



BLEOTORRHAGIC ARTHRITIS. 161 

throughout the whole progress of the disease. But fever may 
supervene, though it existed not at the commencement. In every 
instance, even when the inflammation is most decided, the febrile 
excitement bears no comparison with the intensity of the rheu- 
matism. 

The disease at the beginning having some characteristics of 
chronic affections, we need not be astonished to see it protracted 
for months at least, by one of its elements — the effusion into the 
synovial cavity. But in ordinary, uncomplicated cases, and under 
the influence of well-directed treatment, the affection subsides in 
from three to six weeks. It is not uncommon for a certain quantity 
of the effused fluid to remain in the synovial cavity. We sometimes 
see the disease pass from one joint to the other, or give way to a 
blennorrhagic ophthalmia. It is much more rare to observe puru- 
lent synovitis, but the fact of its occasional occurrence is unques- 
tionable, a circumstance not observed in ordinary rheumatism, in 
which, indeed, we know that more than one pathologist will not admit 
the occurrence of suppuration. But, even in blennorrhagic arthritis, 
under particular circumstances, some complication may aggravate 
the inflammation until it reaches the stage of suppuration. Moreover, 
I had an opportunity of witnessing this accident while attached to 
the Lourcine. The patient had been guilty of no imprudence, he 
was quiet, and had submitted to no injurious treatment, yet he 
was attacked with an inflammation of the knee which terminated 
in abscesses which I was obliged to open. He had in fact a white 
swelling, which I had the good fortune to cure, but at the expense 
of a complete anchylosis. 

Diagnosis. — We must not confound with blennorrhagic arthritis, 
the rheumatic pains which a patient suffers while laboring under 
syphilis. The latter are intermittent, nocturnal, and are aggravated 
by the warmth of a bed ; they are relieved by, and even disappear 
under, the influence of cold, and of motion, and are not increased 
by pressure. As in blennorrhagic arthritis, several joints may be* 
involved, and as ordinary rheumatism may like it assume a chronic 
form ; the disease in question is liable to be confounded with the 
rheumatism which merely coincides with, but has no dependence 
on, a blennorrhagia. What I have stated concerning the suppress- 
ion or the diminution of the discharge when the jpints become' 
affected, does not corroborate the opinion of those who pretend 
from this circumstance to form an opinion of the nature of the 
disease. The discharge, indeed, may not be changed by the oc- 
currence of the urethritis, as it occurs most frequently at a pe- 
riod when the former is so slight, that the articulations become 
involved. 

Thus, there are cases in which the diagnosis, :& difficult, a fact, 
however, of no great importance in a therapeutical point of 
view. 

In the majority of cases, in which the disease is well marked, 
the diagnosis is easily established. For example, if during the 
progress or decline of a blennorrhagia, we observe an aifection of 
a single joint, supervening suddenly, and without any apparent 

11 



162 TIDAL ON VENEREAL DISEASES. 

cause, especially if it be seated in the knee joint, if there is 
neither severe pain, discoloration, nor heat of the skin, and if 
there is no fever, we 'may affirm that the disease is a blennorrhagic 
arthritis ; we may be still more certain, if during a previous 
attack of blennorrhagia, the patient suffered from the same acci- 
dent. 

Treatment. — Those who believe in the general idea of metastatis, 
have recommended the re-establishment of the discharge. For 
this purpose they have irritated the urethra with bougies, and 
have even inoculated it with muco-pus borrowed from another 
patient. In the Bibliotlilque medicate* a case is recorded by Dr. 
Yvan, which seems favorable to this practice, not yet, as it deserves 
to be, abandoned. 

Swediaur applied his treatment directly to the articulation, and 
made use of only mild, diluent drinks internally. His local treat- 
ment consisted of frictions with ammoniacal liniment, and espe- 
cially with an ointment into the composition of which entered the 
gum-resin ammoniacum, dissolved in the vinegar of squills. 

My own treatment consists in the application of from twenty 
to thirty leeches over the skin nearest to the synovial membrane. 
The patient must be feeble, indeed, if I abstain from their use in 
the onset of the disease, for I have observed that the cure is much 
more rapid and complete, when blood has been abstracted. The 
indications for blood-letting are much more positive when the dis- 
ease assumes the decidedly inflammatory form, especially when 
there is reason to apprehend suppuration ; in such a case general 
should precede the local abstraction of blood. Afterwards, I ap- 
ply a large camphorated blister ; this is not kept constantly open, 
but is renewed when we wish for a length of time to maintain 
counter-irritation. If fluid still remain in the articulation, and the 
swelling continue, which is very frequently the case, I employ 
compression by means of narrow imbricated bands of plaster. 
•Sometimes I have applied the dextrine immovable apparatus as in 
cases of fracture. The patient is then not generally condemned 
to preserve absolute repose. Constipation should be obviated by 
saline purgatives, the nitrate (sulphate) of magnesia, or Seidlitz 
water. M. Eicord gives daily from two to four drachms of nitrate 
of potass, and from one to two drachms of tincture of colchicum 
in a tisane of borage. I seldom use liniments or pommades. 
However, in a case where the synovial membrane was actively in- 
flamed, I gave wonderful relief by the application of large quan- 
tities of mercurial ointment. In such a case the ointment should 
be extensively applied as it sometimes is in the treatment of peri- 
tonitis. But if we continue its application for a length of time, 
salivation occurs, which is occasionally a serious annoyance. 

M. Velpeau employs the mercurial ointment, but in a milder 
form, and combines it with a little extract of opium. The same 
surgeon also administers an alterative powder, according to the 
following formula : 

* T. jrii. p. 116. 



BALAMXPREPUTIAL BLENNORRHAGIA. 163 

I£. Calomel, grs. 5. 
Ipecac. u 8. 
Rhei, " 12. 

Divide in six powders. Give from two to six in the day. The object 
is not to excite vomiting, but to maintain a state of constant nausea. 

When the articular inflammation has yielded, and the effusion 
is nearly absorbed, we generally find that the discharge from the 
urethra reappears ; then only do I resort to the use of antiblen- 
norrhagics. I believe that they are entirely useless at any other 
period of the disease ; that is, when it truly exists, and their use is 
not unattended with inconveniences. 



SECTION II. 

BALANO-PREPUTIAL BLENNORRHAGIA. 

This is also called bastard chaudepisse, or external blennorrhagia, 
(Desruelles) ; and balano-posthitis. It consists in a kind of inflam- 
mation of the prepuce and glans, with or without erosions. When 
the disease is confined to the mucous membrane covering the 
glans, it constitutes balanitis ; if the prepuce alone is involved, it 
is then called posthitis* This disease, which possesses much 
interest in a practical point of view, has been much neglected by 
almost every syphilographer. Astruc and Hunter form excep- 
tions to these remarks ; vet their account of it was very incom- 
plete. MM. Desruelles (Traite des maladies veneriennes) and de 
Castelneau {Annates des maladies de la peau et de la syphilis, t. ii.) 
have carefully studied this affection in its different forms, and their 
writings may be perused with profit. 

External blennorrhagia is of frequent occurrence, it being found 
in about one of every thirty admitted into the venereal wards. 
This number should be still higher, and should exceed that of 
urethral blennorrhagia, considering that the prepuce and glans are 
brought more directly into contact with the contagious matter and 
the parts affected. 

Causes. — It is evident that phymosis more or less decided con- 
stitutes a favorable predisposition ; the importance of this condi- 
tion in favoring the development of this disease, however, should 
not be so exaggerated as to deny the possibility of the existence 
of it, except in those whose prepuce is long and narrow, for it 
does occur when the opposite condition obtains, when the glans is 
uncovered, and when the prepuce may be easily retracted. I have 
observed it in a subject on whom I operated for phimosis by cir- 
cumcision. There is one circumstance which has caused the ad- 

* For the sake of brevity, I shall often use the term balanitis, no matter what 
the seat of the inflammation. 



164 YIDAL ON YENEREAL DISEASES. 

mission in the etiology of this affection of too many cases of phi- 
mosis, and that is, that no distinction is made between that which 
is congenital and that which is acquired ; the effect has here been 
mistaken for the cause ; thus, in the case of a prepuce a little 
longer than natural, a balano-posthitis becomes developed, the 
prepuce swells, becomes elongated, the mucous membrane is tur- 
gid, its opening contracted ; in fine, accidental phimosis is estab- 
lished ; it is now regarded as a congenital phimosis, especially if 
the patient be not questioned about the state of the parts before 
the invasion of the disease. Balano-posthitis is certainly observed 
most frequently at adult age. However, at both extremes of life 
this affection is not very rare. Children have sometimes a dis- 
charge from the penis, arising from an inflammation of the lining 
membrane of the prepuce. During my direction -of the wards for 
nurses at the Lourcine, I operated on a nursling affected with 
numerous adhesions between the prepuce and the glans, which led 
to the suspicion of a balanitis during the period of intra-uterine 
life. In old men, balanitis is generally complicated with eczema- 
tous eruptions. 

The syphilitic virus, directly applied, or acting through a con- 
tamination of the system, is unquestionably the most common 
cause of balano-posthitis, whence it may be both primary and 
consecutive. Next to the venereal virus must be placed the 
dartrous vice. A physical agent, the too frequent excitation 
from masturbation, coitus, want of cleanliness, the contact of the 
discharge of leucorrhcea, the menstrual fluid, cancerous ichor, all 
these causes may inflame the mucous membrane of the prepuce 
and the glans. The other affections of this membrane, such as 
herpes, eczema, vegetations, and chancres, are often connected 
with more or less catarrhal inflammation, and it is known, that 
muco-pus, in issuing from the urethra, may, even on the same 
subject, give rise to a balano-posthitis. Among the causes of this 
disease, the agency of foreign bodies must not be forgotten. The 
most common of these are urinary calculi, and other concretions, 
arising from the secretion of the mucous follicles, which has been 
allowed to accumulate within a narrow prepuce by those who are 
negligent of their persons. 

Symptoms and Progress. — The first symptoms of this disease are 
generally observed two or three days after a suspected coitus. At 
the onset there are pruritus and heat ; these are followed by a 
smarting sensation, and finally there appears at the preputial 
opening, a certain quantity of muco-purulent matter. If we un- 
cover the glans, and examine the whole mucous membrane, we 
find that its color is increased, the redness being more marked on 
the glans than on the prepuce. Sometimes the color of a portion 
only of this membrane is changed, either on the prepuce or the 
glans. The epithelium often exfoliates and deliquesces, and the 
denuded, unpolished, mucous membrane, then appears of a deeper 
red color ; it is an erosion, an exulceration, or a blistered surface, 
such as is frequently observed on the neck of the uterus, and on 
the os tineas. The mucous membrane itself may be destroyed, 



Pl.l 




Fi( 




ha I.- 7/>s//e Ar^/A/ti.j /rv/A .x/A/tAsvf/ / tt&e-ttzjfc&rz 



0/?£ww 



'v/Afv/^-A^jfA/Aj f/v'/A J //Art AfetaA fit/ee&aAU 



BALANO-PREPUTIAL BLENNOKRHAGIA. 165 

and a true ulcer be formed. "Whatever may be the loss of sub- 
stance, it is not preceded bj any vesicle or pustule. 

The two forms, the exulcerative and the ulcerative, may occur 
isolated on the lining membrane of the glans or prepuce, or con- 
jointly on both surfaces. I have actually before me a young man 
of a lymphatic temperament, in whom the whole mucous lining 
of the prepuce has exulcerated, whilst not even the color of that 
covering the glans is changed. Plate 1st, Fig. 1st, represents the 
inflammation which is limited to the prepuce. The patient was 
28 years of age, a baker by trade, and of a lymphatic tempera- 
ment. He was admitted March 1st, 1852, into Ward No. 9, Bed 
No. 9. No venereal affection had preceded the attack. Fifteen 
days before his admission, he had connection with a female. Eight 
days afterwards, he discovered a tumefaction of the prepuce, and 
there was dimculty in uncovering the glans. Pruritus, and a light 
pain, existed at the extremity of the penis. At the time of his 
admission (March 1st), I found the prepuce slightly swollen. 
There was some dimculty in exposing the glans. The internal 
face of the prepuce is of a fine red color, and slightly turgid ; it is 
excoriated, and denuded like a blistered surface ; on this reddened 
base, at different points, are whitish spots, consisting of epithelium 
slightly raised, but not yet detached. The glans is perfectly 
sound. Neither pain nor itching is felt at this part ; there is a 
slight discharge between the prepuce and the glans. No discharge 
from the urethra ; the inguinal glands are not enlarged. Until 
the 4th March, the patient applied only emollient lotions to the 
parts affected. It presents the same aspect. March 5th. Apply 
nitrate of silver lotions (three grs. to six oz. of water) ; the surface 
becomes paler ; no pain, and scarcely a weeping between the pre- 
puce and the glans. The lotions are continued until the 10th of 
March, at which period the cure is complete. The patient asks 
for his discharge. 

I have given this case in detail, because it is one of the most 
perfect examples of the localization of an inflammation of the 
mucous lining of the prepuce, and as it is one of the lightest 
forms of excoriation. The cure, as we have seen, was very rapid. 

Most generally we find that the excoriation occurs both on the 
mucous membrane of the prepuce, and the glans ; and it is par- 
ticularly upon the latter that it is most extensive and decided. 
The exulceration is always multiple ; sometimes its limits are not 
perfectly defined, and it is then difficult to distinguish it from a 
simple redness. The erosions are most frequently observed upon 
the glans ; they are of an irregular shape, and have a tendency 
rather to the circular form. Their dimensions range from two to 
six lines ; when of larger size, it is owing to the fact that several 
have coalesced to form but one. The color of the eroded surface 
is of a deep or vinous red, rarely blended with gray, and more 
rarely still of a perfectly gray color, as is seen in the common 
chancre. I have already compared the erosion to a blistered sur- 
face ; but, whilst in the latter there is almost always a pseudo- 
membraneous formation, this is a rare occurrence in the erosion 



166 VIDAL ON VEiTOREAL diseases. 

of the balano-preputial mucous membrane. Around the erosion, 
the color of the glans is of a lively red, often analogous to that in 
the exulceration, and when the limits of the latter are not clearly 
defined, the denuded portion may be confounded with that which 
is not. But it must be admitted, that on the glans this confusion 
is more difficult than on the neck of the uterus. If it be desired 
to make a precise diagnosis, we pass a pair of forceps soaked in a 
solution of nitrate of silver, which will render the eroded surface 
whiter than the polished mucous membrane. In the instances of 
consecutive balanitis, the parts of the glans not eroded retain their 
natural color. 

The matter secreted by a balanitis is at first small in quantity, 
and resembles muddy mucilage, after which it assumes the char- 
acters of muco-pus, and even of pus itself ; like the urethral blen- 
norrhagia, it becomes of a yellow, greenish, and sometimes rusty 
tint ; it has an odor like that from spoiled fish. This discharge is 
sometimes very abundant, and then, if the prepuce is very nar- 
row, its passage through the preputial opening is obstructed, it 
may accumulate in the groove below the glands, and produce to- 
wards the base of this organ a kind of abscess, the evacuation of 
which may require a perforation of the prepuce. Sometimes the 
quantity of matter secreted is very small ; in chronic cases, when 
we expose the glans, we discover a thin crust formed over the 
eroded surfaces, which falls off to make room for others. 

The progress of balano-preputial blennorrhagia is generally 
rapid, and it soon becomes healed, even when there are exulcera- 
tion and superficial ulceration. Cleanliness, the most simple topi- 
cal applications, singularly promote and hasten this happy termi- 
nation, which sometimes happens in the course of four or five days. 
But this does not occur when complications exist, and when the 
cause cannot be removed. 

The first case detailed below affords an example of one of the 
most simple acute cases. In the second, not only the glans and 
prepuce were affected, but this had been preceded by an urethritis 
which was followed by a vegetation. It is evident that the bala- 
no-posthitis was chronic ; I regarded it as consecutive. 

Gr. L., aet 19, shoemaker, of lymphatic temperament, good con- 
stitution, was admitted March 15th, 1852, into Ward ISTo. 11, bed 
No. 31, of the Hopital du Midi. 

Nine months and eight days before his admission, after connec- 
tion with a prostitute, he was attached with a slight urethral dis- 
charge, accompanied with slight pains during the emission of urine. 
This condition lasted six months. ISTo treatment. At this period, 
and without any apparent cause, the prepuce became swollen, red, 
and painful ; the glans could no longer be uncovered. A very 
copious discharge was formed between the prepuce and the glans. 
Ordered local baths. Eegimen and tisanes for eight clays. There 
was scarcely any discharge from the urethra. The prepuce being 
no longer swollen he could expose the glans, the surfaces of both 
prepuce and glans are only a little reddened. He returned to his 
accustomed habits, drinking, &c. ; fifteen days afterwards, the ure- 



BALAXO-PREPUTIAL BLENNORRHAGIA. 167 

thral cliscliarge reappeared; the prepuce became again swollen, 
and there was a renewal of the phimosis. (The patient has been 
continent since the coitus before mentioned.) In this condition 
he remained until admitted into the hospital, (March 15th.) 

loth. Some difficulty in uncovering the glans. The prepuce 
somewhat swollen ; its lining membrane reel, granulated, and bleed- 
ing from the slightest cause ; the color of the glans is of a bluish 
gray ; it presents broad layers of a slightly brownish red ; these 
are excoriations which bleed occasionally. Discharge slight, thick, 
and of a greenish yellow color between the prepuce and the glans ; 
weeping from the meatus ; no pain. On exposing the glans, in the 
groove around it, on the right side and near the frenum, is found 
a vegetation of a deep red color. The inguinal glands are more 
engorged on the right than on the left side, but they are not pain- 
ful. The patient did not discover them ; he remembers, besides, 
that in his childhood he had enlarged glands in the neck. The 
cervical ganglia are now normal. Bath. 

16th. A sketch is made of the penis; it is represented in Plate I. 
Fig. 2. The glans is excoriated, together with the prepuce ; the 
latter being somewhat narrow forms a kind of ligature around the 
base of the penis. The redness at the base of the excoriations is 
less brilliant than that in Fig. 1 ; it is slightly brownish. 

17th. The prepuce, which yesterday was drawn behind the glans, 
is greatly swollen. Its surface, with that of the groove, has lost, 
in consequence of their isolation, the tint which they possessed 
yesterday. Prescribed lotions of nitrate of silver of the strength 
mentioned in the preceding case. 

18th. The parts have assumed a brownish color ; here and there 
some reddish points remained. Discharge has increased. 

19th. Bath. The parts appear perfectly sound. The vegetation 
is shrivelled and detached, from the effects of the application of a 
powder composed of equal parts of savine and burnt alum. 

29th. No traces of the vegetation. Patient now takes Dupuy- 
tren's pills ; there is still a slight weeping from the canal.* 

Complications. — The phimosis, which is a cause of balanitis, may 
become a complication, by obstructing the discharge of the matter 
secreted, and by resisting the development of the glans, which 
occasionally gives rise to a strangulation and sloughing of the pre- 
puce; it is owing to this complication particularly, that balano- 
posthitis becomes very painful. Again, the inflammation may not 
be confined to the mucous lining of the preputial cavity ; it may 
involve the glans, and the cellular membrane between the mucous 
lining and the skin, and even the skin itself, causing it to assume 
a phlegmonous character. Two sets of vessels are distributed 
between the skin and lining membranes of the prepuce ; viz. veins 
and lymphatics, and these become inflamed. According to M. 
Desruelles, phlebitis is a much more frequent complication than 
inflammation of the lymphatics. The reverse of this is true. But 
it must be admitted, that before the investigations of this physician, 

* Case reported by M. Codet, interne du service. 



168 VEDAL ON VENEREAL DISEASES. 

the attention of observers was not so strongly fixed npon the 
inflammation of the principal veins of the penis, and of the capil- 
lary veins, an inflammation which gives at once a serious character 
to balano-posthitis. 

When all these anatomical elements of the prepuce become 
invaded, the extremity of the penis becomes increased in size ; it 
assumes the form of a club, it becomes red, and then changes to a 
violet color. If the prepuce is long, we find it twisted at its 
extremity, and narrow, and appears as if pediculated at a point cor- 
responding to the glans ; it is more developed anteriorly, and there 
is occasionally a hernia of the mucous membrane. Then we may 
have not only a retention of the matter secreted, but a retention 
of urine, which, however, is much more rare. This complication 
has more than once rendered it necessary to divide the prepuce, 
notwithstanding the risk incurred by this proceeding of inoculating 
the wound. 

Blennorrhagia, chancre, and buboes are often rather conse- 
quences than true complications of the disease. Chancre is more 
frequently observed than blennorrhagia ; bubo, resulting from the 
latter affection, is very rare, and as we shall hereafter find, it may 
become virulent. The vegetations and mucous tubercles which 
may give rise to balanitis, are also sometimes consequences of this 
affection. (In Plate I. Fig. 2, a vegetation is represented.) Thus, 
it is common to see numerous vegetations arise from the reflexion 
of the prepuce lately occupied by an erosion, or blennorrhagic 
inflammation. Orchitis has improperly been regarded as a com- 
plication or one of the accidents of balano-posthitis. 

Terminations. — The most frequent is resolution, or prompt re- 
covery, if the complications are removed, if the causes no longer 
exist, and if the disease has not been aggravated by improper treat- 
ment. When balanitis is consecutive, the duration of the disease 
is considerably increased, or it may be reproduced. When it 
arises from eczema, as is often the case in old men, it may be very 
obstinate. 

Diagnosis. — When the prepuce is narrow, balanitis may be con- 
founded with urethritis, for both inflammations may cause the 
same matter to be secreted, the same muco-pus. But the emission 
of urine is generally not modified, or is not more frequent than 
usual in balanitis ; the pain is limited to the glans ; the discharge 
is as copious before as after urinating ; and erections are not com- 
mon. In urethritis, the pain at length always extends to several 
points in the urethra ; those which are felt in urinating are especially 
referred to the perineum; there is more frequent disposition to 
urinate, and by pressing the urethra from the scrotum towards the 
glans, we considerably augment the quantity of matter which 
escapes from the prepuce. 

Chancre of the preputial cavity may simulate balanitis, but gen- 
erally it furnishes less matter than the latter, and by carefully feel- 
ing, we may often detect an induration which reveals chancrous 
ulceration. When the glans can be exposed, other difficulties may 
still exist. Thus simple excoriations may be confounded with the 






BALANO-PREPUTIAL BLENNORRHAGIA. 169 

truly specific exulceration, the primary exulceration to which the 
former are consecutive. Simple excoriations are ordinarily less 
extensive, very irregular, and of a fine red color ; their secretion 
is small in quantity ; on evaporation, crusts and yellowish pelli- 
cles are formed, and the vicinity of the glans is colored and irri- 
tated to an extraordinary degree. The consecutive erosions are 
of a rounder form ; the pellicle by which they are covered falls 
off readily in the form of scales, leaving behind a gloss of a red- 
dish brown tint (syphilitic tint). It is rare that there are not as- 
sociated with these some of the syphilitic eruptions. Eczema, 
also, leaves excoriations which may be confounded with those of 
true balanitis, but they are preceded or followed by little vesicles ; 
the itching is troublesome, and the affection is often seen on other 
parts of the integuments. 

Prognosis. — This may be inferred from what I have stated con- 
cerning the terminations. Like the local affection, this is most 
benign when uncomplicated, but, even when it exists in its mild- 
est form, that which is regarded as simply catarrhal, it may be 
the starting point of syphilitic infection. 

Nature. — The same diversity of opinion here prevails as in ref- 
erence to the nature of urethral blennorrhagia. But, as the parts 
affected may here be directly explored, in the majority of cases, 
and as the chancre larve cannot conceal the truth, the latter may 
be obtained both by clinical and experimental observation. Ex- 
perience, indeed, has shown that balanitis, in both its forms, that 
is, without and with erosions, has been followed by consecutive ac- 
cidents, which revealed the existence of constitutional infection. 
Experiments have corroborated these remarks ; that is, they have 
established the fact, that the matter secreted in a mucous balano- 
posthitis may be successfully inoculated, and that, too, when there 
is no ulceration, nor the slightest erosion, or solution of continuity 
in the mucous membrane. 

Clinical facts could not be denied ; they, however, have- been 
explained in a manner different from our own. The experimental 
facts have simply been denied. These facts, however, occurred at 
the Hopital du Midi ; they have been collected by an interne with 
whom I am acquainted, and have been inserted in his inaugural 
thesis. Dr. Bartholi asserts even that he has met with thirty cases 
of this kind. One of these is very remarkable ; in a case of bala- 
nitis, without the slightest exfoliation of the mucous membrane, 
without any other venereal symptom, an adenitis supervened, 
which was treated by numerous punctures. Each puncture be- 
came transformed into a chancre. Pus taken from one of these 
ulcerations, and inoculated, produced what is called at the Hopital 
du Midi the pustule caracteristique ; in other words, that which pre- 
cedes chancre. (The Thesis of M. Bartholi was defended at Paris, 
in 1845 ; it was on the subject of Syphilis and Scrofula.) I have 
not repeated these experiments, because the syphilitic nature of 
balanitis, under the form which is called simple catarrhal, I have 
never doubted, since I have been able to watch for a length of time 
the patients in whom it occurs. 



170 VIDAL ON VENEREAL DISEASES. 

It is, therefore, demonstrated that balano-preputial blennor- 
rhagia, in its ulcerated and non-ulcerated forms, may be conta- 
gious, inoculable, and the cause of consecutive accidents, in the 
same manner as certain urethral blennorrhagias. There is this 
difference, however, viz., that matters here are more easily de- 
tected, since it is an external blennorrhagia, a disease which is 
completely under our observation. Thus, in my opinion, the his- 
tory of this throws much light on the history of all other forms of 
blennorrhagia. 

[Mr. Langston Parker (pp. cit. p. 34,) states that in this form of 
disease, he has seen eruptions, accompanied by a node on the fore- 
head, loss of the hair, and other symptoms of constitutional 
syphilis, produced in the wife, where this species of abrasion, with 
thickening, were the only symptoms in the husband. — Gr. C. B.] 

Treatment. — I shall here point out only the local treatment, for 
the general or rather the specific treatment, will be taught when 
we come to treat of chancres. This special treatment should be 
adopted whenever we are not certain that the balanitis proceeds 
from a physical or simply irritating cause. 

The local treatment may require nothing more than the observ- 
ance of cleanliness, and the interposition of fine lint between the 
prepuce and the glans. This isolating the parts affected should be 
employed whenever it is possible. Nothing more prevents reso- 
lution than the contact and friction of one diseased mucous sur- 
face upon another. Instead of lint, we may use charpie, or cot- 
ton. I will soon mention with what they should be saturated. In 
the majority of cases,, for simple water lotions, and local baths, we 
substitute lead water, or a solution of the nitrate of silver. The 
formula which I adopt has already been mentioned, while treating 
of blennorrhagia. 

]J. Nit Argent, grs. 3. 
Aq. pur. 3 vi. M. 

M. Baumes prefers ; 

^ . Nit. Argent, grs. viii. 
Aq. pur. % ii. 

M. Desruelles steeps the pledgets in the following solution : 

3. Nit. Argent, gr. xv. 
Aq. § i. 

The glans being covered with these pledgets, the prepuce is 
brought over it. Where it cannot be exposed, we must inject the 
same solution between it and the prepuce. 

1. M. Ricord's treatment. — If he can uncover the glans, he applies 
a crayon of nitrate of silver over the entire diseased surface. He 
then covers it with fine lint, over which he pulls down the pre- 
puce. In the next place he makes use of fomentations by means 
of compresses soaked in Goulard's extract. The lint is changed 
twice a day, and each time, the parts are washed with a weak solu 
tion of lead. 









BALANO-PREPUTLAL BLENNOPRHAGIA. 171 

"When the inflammation runs high, and the disease is compli- 
cated with natural or accidental phimosis, he employs active an- 
tiphlogistics ; he applies leeches to the pubic region, to the genito- 
crural fold on each side, but never to the penis itself. Local baths 
composed of decoctions of marsh-mallow root, of linseed, with 
warm milk, of nightshade, or of poppy heads, may also be used, 
with injections between the prepuce and glans of these mild 
narcotics. One or two scarifications on each side of the lower 
part of the prepuce, when there is much oedema and but little in- 
flammation. This trifling operation must be avoided when there 
is erysipelas, and leeches preferred as already indicated. 

If gangrene threaten, fomentations, with a solution of the 
gummy extract of opium, and injections of the same fluid into the 
preputial cavity ; internally, a grain of opium several times in the 
course of the twenty -four hours. The same narcotic is to be 
administered in lavements with eight or ten grains of camphor. 

2d. Author's treatment. — I employ injections between the pre- 
puce and the glans, of the strength already mentioned, and apply 
a crayon of nitrate of silver, over all the parts affected if they can 
be exposed. I have never found it necessary, however, to resort 
to the local abstraction of blood, nor to scarifications in cases com- 
plicated with inflammation or oedema. From this it must not be 
inferred that I disapprove of the practice to which I have above 
alluded. I wish merely to state my own. When the inflamma- 
tion is very acute, the subject young and plethoric, I prefer 
bleeding from the arm ; I repeat the general bathing, and pre- 
scribe fomentations of the decoction of nightshade, after which I 
cover the penis with a linseed cataplasm moistened with Goulard's 
extract. 

Some practitioners very frequently incise the prepuce, when to 
a congenial or accidental phimosis there is added an inflammatory 
complication. Doubtless, it is often of advantage to promote the 
development of the inflammation as we may thus avoid gangrene. 
But in the preputial cavity there may be a concealed chancre 
when we suspect only an inflammatory balanitis ; the wound may 
thus become inoculated, and be transformed into a large chancre, 
which often becomes phagedenic. I should more willingly advise 
incision, or better still circumcision in the case of chronic inflam- 
mation, especially when it is possible to know that it is limited to 
the glans. For example, a few days since, I operated on a patient 
in such a condition. There was incomplete phimosis, and I could 
assure myself that he had balanitis alone ; I performed circum- 
cision, and applied serre-fines ; the wound was united in thirty 
hours, and the glans, which were very red and excoriated at the 
moment when it was uncovered, soon became pale ; a crust formed 
over the excoriation, which eight days afterwards fell off and was 
not again renewed. There can be no doubt that in this case the 
contact of the lining membrane of the prepuce, with that of the 
glans, did protract the existence of the balanitis. 



172 VIDAL ON VENEREAL DISEASES. 

CHAPTER III. 

BLENNORRHAGIA IN THE FEMALE. 

The specific inflammation which I am about to describe affects 
several mucous tissues. The female may therefore be affected 
with several forms of blennorrhagia, but they are too frequently 
confounded to be described separately, as I did in treating of the 
disease in the male. I prefer to make but two varieties, which I 
will describe under the same head. When the vitality of the fe- 
male genital organs becomes affected, certain morbid secretions 
take place, which have been confounded under the name offluor 
albus, which may give rise to blennorrhagia. The female, there- 
fore, may have a discharge which has not been contracted from 
another, as well as that which has been thus contracted ; for this 
reason it has been asserted, that as regards blennorrhagia she gives 
more than she has received. 

Seat. — Facts do not warrant us in locating the inflammation ex- 
clusively in the vulva, the vagina, or the urethra. Blennorrhagia 
may affect all these parts, though it more frequently commences 
in the vagina. This is all that can be positively asserted. It 
may be limited to one of the localities mentioned, or invade 
several at the same time, and extend over the entire mucous lining 
of the genital organs and urethra. 

Varieties. — I make three varieties of this disease, a division based 
on the particular locality affected. Thus we have a vulvar variety, 
a vaginal, to which I will add a uterine and a urethral. In the two 
first named we shall rind analogies with balano-preputial blennor- 
rhagia, analogies which did not escape the observation of Hunter. 

1st — Vulvar Blennorrhagia. — The vulva comprises, as is well 
known, the clitoris and its prepuce, the vestibule, the labias ma- 
jora and minora, the caruncules, and what is called the vulvar 
circle. These parts may be thought very rarely separately affect- 
ed, in the majority of cases, indeed, the entire vulva being involved. 
The blennorrhagia may be superficial ; in other words, it is simply 
erythematous, and limited to the mucous membrane ; or both the 
glands and tissues invested by this membrane may be invaded by 
the inflammation. Even the skin adjacent to the genital organs 
may suffer, especially in females who are very corpulent. 

Vulvar blennorrhagia is generally accompanied with very 
troublesome itchings, intense heat, marked redness, and tumefac- 
tion. Sometimes there are erosions as in balanitis. In many, the 
invasion of the disease is characterized by strong venereal desires. 
It is rare, however, that this kind of nymphomania continues 
during the whole progress of the blennorrhagia. Walking excites 
the parts, and renders them painful ; sometimes the patient suf- 
fers whilst sitting ; even when urethritis does not exist, the emis- 
sion of urine is painful, especially when it is about finished, and 
the last drops become diffused over the inflamed vulva. 



BLENNORRHAGIA IN THE FEMALE. 173 

There is often, at the same time, an oedematous and inflam- 
matory swelling, which may terminate in the obliteration of the 
yagina in strangulation, and a kind of paraphymosis of the 
nymphae. The urethra sometimes is even compressed, which pro- 
duces pain during the whole time that the urine is voided, for 
there is dysuria. When the inflammation reaches this height, and 
when it involves the skin and parts adjoining the vulva, the dis- 
charge is very acrid, and exhales a very fetid odor. The glands 
invested by the mucous membrane of the vulva, those in the sub- 
stance of the labia, may become inflamed. When it was believed 
that the blennorrhagic discharge consisted entirely of semen, the 
seat of the affection was placed in these glands, which were re- 
garded as reservoirs of the sperm. Thus we find in Astruc that 
" the prostate and Cowper's glands" are considered as the seat of 
blennorrhagia. As regards the female, this author states explic- 
itly that the last-named glands u are situated in the perineum, 
near the anus, and that they open into the vulva " by two ducts 
which may be found at the entrance of the vagina, near the carun- 
cula myrtiformis."* This description evidently applies to the 
glandular bodies recently described by my colleague I)r. Huguier. 
Now then, these glands may become inflamed in like manner 
with the follicular bodies which are more or less deeply situated, 
and there vulvitis assumes a phlegmonous form ; abscesses form, 
which if not early opened, may produce a blind fistula ; that is, 
with an opening only in the vulva, or it may rise to a complete 
fistula, with an opening in the rectum very near the anus, as well 
as that in the vulva. Long since I described the characters of 
these abscesses, and pointed out the consequences which might 
follow. In proportion as vulvitis is more or less superficial and 
recent, and according to its depth and extent, it may produce a 
discharge which is at first mucous, which afterwards becomes 
muco-purulent, and finally entirely purulent. When there is sup- 
puration of the glands, the pus secreted may present all of these 
characters. If the inflammation involves the adjacent skin, there 
oozes from its surface a humor like that produced by a blister. 
The fetor is then especially intolerable. 

Yulvitus is very frequently observed in little girls who have a 
somewhat lymphatic temperament. It is manifested, in the first 
place, by a mucous discharge, which by degrees becomes trouble- 
some ; it may be attended with an itching sensation, and occasion- 
ally with acute pain. In the majority of cases this blennorrhagia 
is spontaneous ; seldom is it caused by contagion. 

2d. Vaginal-uterine Blennorrhagia. — Under this head I shall con- 
sider not only the affection limited in its seat to the vagina, but 
that which reaches as high as the uterus. Vaginitis is an exten- 
sion of vulvitis, or, what is most common, it commences in the 
vagina itself. This canal may be affected throughout its entire 
extent, or in that portion only which lies adjacent to the vulva, or 
to the neck of the uterus. If the disease is confined to this last- 

* Traite des maladies veneriennes, t. iii. p. 7. 



174 VIDAL ON VENEREAL DISEASES. 

named part, and if the discharge accumulate in this cul-de-sac, on 
a superficial examination we may pronounce a female sound when, 
in fact, she is the receptacle of what may readily infect whoever 
shall have intercourse with her. The finger should be introduced 
deeply into the vagina, its posterior face depressed, by which a 
cavity will be formed. We then perceive the matter threading 
its way along the finger to arrive at the vulva. It is still bet- 
ter, when possible, to examine carefully with the speculum the 
condition of the mucous-membrane as we withdraw the instru- 
ment. 

The inflammation may still be here only erythematous, catarrhal, 
or phlegmonous, according as it is limited to the mucous surface, 
or as it involves the tegumentary covering and mucous follicles, a 
complication which renders the vaginitis very intractable. In 
speaking of vulvitis, I have not mentioned the phenomena which 
occur in the genital regions, as well as parts more remote, because 
they are very rare; but when vaginitis exists, it is common to 
hear the female complain of a feeling of weight and uneasiness in 
the groins, of pains in the pelvis, of general uneasiness, and of 
painful lassitude. The local pain is here less severe ; some women 
indeed never suffer during the whole progress of the disease, and 
coitus is attended with no disagreeable sensation ; now, as they 
are more than ever troubled with desire, the men with whom they 
are intimate are much exposed to infection. The same danger 
does not exist in vulvitis, for no matter what the desires of the 
female, sexual intercourse is then so painful as to be rendered 
almost impossible. If the pain in vaginitis is less, the discharge, 
on the contrary, is more considerable than in vulvitis. An inspec- 
tion of the vagina shows the lining membrane redder than in its 
natural state ; the redness is deep and bright, and is principally 
remarked on the vaginal folds, which are then unusually prom- 
inent. Sometimes the surface of the vagina has the aspect of a ' 
granulating wound ; then it has received the name of papulous or 
granular vaginitis. M. Deville believes it to be peculiar to preg- 
nancy ; true, it is most frequently observed in pregnant females, 
but it may also occur in those who are not in this condition. 

As in the male, blennorrhagia is observed to commence in the 
fossa navicularis, traverse the urethra, even to its most deeply- 
seated parts, and then become chronic, and complicated with pros- 
tatic engorgement ; so in the female, it may be seen to attack first 
the vulva, then pass through the vagina, and fix itself upon the 
cul-de-sac, about the neck of the uterus, which then suffers several 
different pathological modifications. These modifications, by 
the secretions to which they give rise, it may be remarked, are the 
most frequent cause of communicating blennorrhagia. In this 
chronic state, the female no longer suffers during coitus ; the dis- 
ease being of long standing, she thinks that it has passed, and the 
morbid secretions are confounded with leucorrhoea. The blen- 
norrhagia may even extend farther ; it may pass through the neck, 
and involve the body of the uterus. The discharge is then more 
of a mucous character, and issues from the vagina in thready 



BLEMOKRHAGIA W THE FEMALE. 175 

masses ; it lias a tenacity that does not belong to it, when vagini- 
tis alone exists. 

[The sterility of prostitutes is attributed, by several authorities — 
as, for example, Mr. Henry J. Johnson, op. cit. p. 340 ; Mr. Egan, 
op. cit. p. 123 ; and Mr. Acton, op. cit. p. 200 — to the occlusion 
of the uterine cavity by the tenacious, stringy mucus, secreted by 
the glands of ISTaboth, which so frequently exist in this class of 
persons in a state of chronic inflammation. This viscid discharge 
occurs also in connection with a granular state of the cervix. 
Young married women affected with leucorrhoea are often barren 
from the same cause. — Gr. C. B.] 

There is reason for believing that the inflammation may reach 
the ovaries even through the Fallopian tubes, as it does the testicle 
through the vas deferens, at a certain period of urethral blennor- 
rhagia in the male. "When I come to treat of the accidents, I shall 
mention certain facts which would seem to authorize the admission 
of a blennorrhagic ovaritis, analagous to blennorhagic orchitis. 

3. Urethral Blennorrhagia. — The symptoms are not unlike those 
of urethritis in the male. Sometimes there is a slight itching and 
uneasiness, which becomes changed to a real pain, and, during the 
emission of urine, it is of a burning character. To determine 
absolutely that the urethra is really the seat of the pain, we intro- 
duce the index finger into the vagina, turn its palmar face towards 
the pubis, and press the urethra, from the neck of the bladder to- 
wards the meatus. If urethritis exists, the band formed by the 
urethra in the vagina appears increased in size ; it is more sensible, 
and the pressure gives exit to a quantity more or less considerable 
of muco-pus. 

Accidents. — These are less numerous in the female than the male. 
In the latter, we may have prostatitis and epididymitis ; blennor- 
rhagic ophthalmia and arthritis are less frequently observed. In- 
flammation of the body, and especially of the neck of the bladder, 
is by no means so common as in the male. An accident which 
may be regarded as analogous to orchitis, is ovaritis. I have often 
observed it ; and it has not escaped the attention of M. Eicord ; 
very recently, M. Mercier has proved, by an autopsy, that the 
inflammation may invade not only the Fallopian tubes and 
ovaries, but even extend to the peritoneum, producing an inflam- 
mation of this membrane, an obliteration of the Fallopian tubes, 
and thus become a cause of sterility. 

The following are the symptoms of blennorrhagic ovaritis. 
After vulvitis and vaginitis, and the manifestation of symptoms 
showing an affection of the uterus, pains are felt in one or both 
iliac regions, and there is pain, tension, and swelling, with pain 
on pressure. A symptom which M. Eicord has observed to be 
constant, and to which he attaches the greatest importance, is the 
following : whenever the patient lies on the side affected, the pain 
diminishes, for with the change in position, the dragging on the 
organ affected is lessened, and consequently the pain to which it 
gives rise. 

[Mr. Acton observes (op. cit. p. 209), that if the finger be car- 



176 YIDAL ON VENEREAL DISEASES. 

ried up the cul-de-sac of the vagina, and the patient desired to turn 
upon the opposite side, pain of a most acute kind will be felt. — 
G. C. B.] 

The inflammation is occasionally propagated to the uterus and 
ovaries, not during the intensity of the vaginitis, but after a cer- 
tain period, as we observe orchitis in the male to occur after the 
second or third week of the blennorrhagia. Generally, the most 
perfect analogy exists between blennorrhagia ovaritis and orchitis. 
A cure is almost always obtained. Suppuration rarely occurs. 
I think, however, that I have observed it in a single instance. 
The case was one of ovaritis, following an intense vaginitis which 
extended to the uterus. There was severe pain in both iliac re- 
gions, which pains, however, were not sensibly increased by pres- 
sure. On examining these regions, after having evacuated the 
large intestines by two enemas, an indurated space was felt ; 
there were cramps in the lower extremities. Yomiting and pain 
in the stomach manifested themselves. The pulse was moderately 
accelerated, and very soft. Cephalagia. Ten days after the ap- 
pearance of the first symptoms of ovaritis, when the pains had 
ceased, when all was tranquil, I introduced the speculum. 
Scarcely had it entered, when there issued from the neck of the 
uterus a large quantity of well- formed pus, having a most repuls- 
ive odor. It was my opinion that this pus came from the ovaries, 
having reached the uterus through the Fallopian tubes, or by some 
solution of continuity in the substance of that organ. 

I insert in this place, the particulars of an important case which 
has been recorded by M. Mercier. It sheds some light upon the 
pathological anatomy of blennorrhagia, as it exists in the female 
in its most severe and extensive form. "We find every part to 
which I have alluded as the seat of blennorrhagia, affected. There 
were indeed traces of vulvitis, urethritis, vaginitis, metritis, 
&c, &c. 

" A girl, set. 19, some weeks since, was attacked, whilst labor- 
ing under blennorrhagia, with the premonitory symptoms of ty- 
phoid fever. During this period, she was seized with an intense 
pain in the pelvis : the application of forty leeches produced an 
abatement of the pain, but the typhoid fever steadily progressed, 
and at the end of a month the patient died. The following ap- 
pearances presented at the autopsy : 

" In the intestinal canal, there were about sixty ulcers of vari- 
ous dimensions. The internal surface of the labia majora were 
red and turgid ; on the left, at various points were found excoria- 
tions. The nymphse were covered with compact granulations of 
the size of a pin's head. The bladder, which was very small, con- 
tained a little purulent urine. Its lining membrane was red, 
especially in the vicinity of the ureters and the urethral orifice. 
The urethra at its inferior part, for about three lines in extent, 
presented a uniform, deep red tint. Above this point, there were 
very numerous red spots. The vagina, for an inch and a half 
above the vulva, was of an intensely red color. Its transverse 
folds were here also unusually prominent, especially anteriorly, 



BLENNORRHAGIA m THE FEMALE. 177 

where were found small compact projections, resembling little 
vegetations. Higher up, the redness was less marked. 

" The neck of the uterus was somewhat redder than the sur- 
rounding portion of the vagina. Its opening, which presented the 
appearance of a very broad transverse cleft, indicated that this 
woman had been a mother. The color of the cavity of the neck 
was almost violet. The substance of the uterus was not inflamed, 
but the color .of the membrane lining its cavity, was like that of 
very red wine. The inflammation extended to the Fallopian 
tubes, which were not obliterated on the side of the uterus. The 
cavities of these different parts contained a large quantity of muco- 
pus ; but no ulcerations were found. 

. " Throughout the whole abdominal cavity, except in the lesser 
pelvis, the peritoneum was perfectly sound. There were no per- 
forations in the intestines. The surface of the peritoneum pre- 
sented nothing unusual ; but in the vesicouterine cul-de-sac be- 
tween the posterior face of the bladder and the anterior surface of 
the uterus, existed reddish false membranes, soft, granular, thin, 
and easily detached. In the utero-rectal cul-de-sac, the peritoneum 
was likewise inflamed, of a livid color at various points, and cov- 
ered with nlimentous adhesions, which extended from the uterus 
to the rectum ; the same adhesions existed on the broad ligaments, 
the ovaries, and Fallopian tubes, to such an extent as to destroy 
all traces of the corpus flmbriatum of the latter on the left side, 
which was obliterated. Notwithstanding the numerous adhesions 
which surrounded the right pavilion, its cavity still communicated 
with the peritoneum."* 

If typhoid fever had not destroyed this female, and she had 
lived with the pavilion of the left Fallopian tube obliterated, the 
corpus flmbriatum on the right side being in such a condition as 
to prevent the inclination of the pavilion of this side towards the 
ovary, sterility must have been the consequence. Besides, this is 
not the first time that obliterations of the pavilion and the Fallo- 
pian tubes have been found in females affected with the venereal 
disease. This fact was noticed even by Morgagni. M. Mercier 
has suggested that this may be the principal cause of sterility in 
prostitutes. 

Diagnosis. — In the description given of the three varieties of 
this disease, I think that I have sufficiently established the diag- 
nosis so far as regards its seat. I have not alluded to the acidity 
of the discharge as a test of vaginitis, nor to its alkaline character 
in other forms of blennorrhagia, nor to the existence of animalcu- 
lse, because it is known that these are far from being constant, 
and from possessing the importance which has. been assigned to 
them. M. Baumes coincides in this opinion. The diagnosis, as 
regards the knowledge of the causes and nature of the discharge, 
is very obscure, more so in the female than the male, and this 
obscurity often proceeds particularly from the existence of leucor- 
rhcea, which strongly resembles blennorrhagia in its symptoms 

* Gazette des Hopitaux, t. viii., 2d series,, p. 432. 
12 



178 VIDAL OX VENEREAL DISEASES. 

and effects ; for, like this disease, it may become contagious. 
Doubtless, by taking into consideration all the circumstances con- 
nected with the disease, the lapse of time after a suspected inter- 
course, the previous liability of the female to become affected with 
discharges, the candid confessions of those who can have no motive 
to deceive, we may arrive at probabilities, though not to absolute 
certainty respecting its nature. The seat of blennorrhagia affords 
no light upon its nature, for that which is urethral is no more 
syphilitic and contagious, than that which affects the vagina. "We 
can learn nothing from the character or color of the stains upon 
the linen ; the pain, which may be present in blennorrhagia and 
absent in leucorrhcea, is a still more fallacious symptom on which 
to rely, for there are discharges, which, at a certain period, have a 
remarkably indolent character, and which are nevertheless very 
contagious and evidently syphilitic. With M. Eicord, the seat of 
blennorrhagia is sufficient to establish its etiology. Thus, accord- 
ing to his researches, urethritis in the female should always be 
the result of contagion. If carefully interrogated, she will admit 
that she has been exposed to a suspicious connection. In cases 
of vulvar and vaginal blennorrhagia, frequently they will not 
admit that they have been thus exposed. Then M. Eicord, so 
incredulous generally, credits and admits the statement of the 
female, as I have already remarked, that the urethral blennor- 
rhagia with which she is affected is the result of contagion, whilst 
the others may be regarded rather as of spontaneous origin. But 
statistics, taken on a large scale, show, that among prostitutes, 
who, of course, are most exposed to infection, urethral blennor- 
rhagia is very rare. 

[It was the opinion of John Hunter, that the urethra in the 
female is seldom the seat of blennorrhagia, but M. Eicord (Notes to 
Hunter, 2d ed., p. 261), states that the female urethra is more fre- 
quently affected than Hunter supposed. Mr. Egan, who enjoyed 
such excellent opportunities for observing blennorrhagia in the 
female, at the Lock Hospital, Dublin, thus expresses his opinion : 
"The urethral variety," he observes, (op. cit. p. 121,) "is seldom 
encountered as a distinct form ; neverthless, it is occasionally met 
with." Having recently had the pleasure of visiting the above 
hospital, which contains 130 female patients, we can cheerfully 
join with Mr. Egan in the assertion, that there are but few institu- 
tions where greater facilities are afforded for investigating venereal 
affections in that class of patients. — Gr. C. B.] 

This point, doubtless, is still involved in obscurity ; but a fact 
which is well established is, that discharges may occur in the 
female, not the result of suspicious intercourse, which, notwith- 
standing, are very contagious. To assert that men who have 
contracted a blennorrhagia from such a source, cannot communi- 
cate it to another female, is, in my opinion, to proclaim an hypo- 
thesis not unattended with danger. 

Prognosis. — The prognosis, viewed in reference to the seat of 
blennorrhagia, has already been noticed in describing the three 
varieties. It is certain that superficial vulvitis, that is, entirely 



BLEOTORRHAGIA IN THE FEMALE. 179 

external, admits of prompt and easy cure. This is not the case 
when it becomes phlegmonous, and when the glands become in- 
volved ; I have already stated, that abscesses may supervene, and 
fistulas, the treatment of which is long and difficult, especially 
when the latter complication exists. Vaginitis, even when super- 
ficial, is generally more difficult to cure than vulvitis ; especially is 
it the case, when the cellular tissue is more or less involved, when 
the whole vagina, and particularly its superior cul-de-sac are 
affected. As regards rapidity of cure urethritis occupies a middle 
position between vulvitis and vaginitis. Urethritis may easily be 
modified by resinous substances, which are known under the name 
of anti-blennorrhagics, but which exert no influence over the other 
varieties. Blennorrhagia is especially obstinate when it affects the 
neck and body of the uterus ; it then assumes a catarrhal form, 
becomes complicated with engorgements which readily pass into 
a chronic state. 

Treatment — "When I was considering the subject of blennor- 
rhagia in general, I pointed out the hygienic and therapeutic 
principles by which we should be guided. In treating of blen- 
norrhagia in the male, I enjoined certain precepts which have 
their application here. It remains to constitute the special treat- 
ment of blennorrhagia in the female, and to render the matter more 
intelligible I will adopt the same divisions as in describing the 
disease in detail. 

1. Vulvar Blennorrhagia. — That which is superficial, in addition 
to general and local bathing, requires the use of pledgets to isolate 
the inflamed surfaces. The weak solutions of nitrate of silver, and 
of acetate of lead, which were recommended in the treatment of 
balanitis, may here be beneficially employed. These means gener- 
ally suffice to cure the local disease in the course of eight days, or 
to manifestly improve it. It must be distinctly understood that we 
here speak of the superficial inflammation of the mucous membrane 
alone. But if it be of a phlegmonous character and the glands are 
involved, then more active treatment is required ; we must then 
occasionally resort to the abstraction of blood ; bathing and the 
topical use of emollient opiated applications should never be omit- 
ted. As with the deep-seated vulvitis chancres may exist at the 
commencement of the vagina, without the caranculsB, chancres 
which, by their extent and position, may sometimes escape our 
attention, we should avoid the use of leeches, as the wounds which 
they inflict about the anus, and the genito-crural fold may easily 
be inoculated. When the female is young, robust, and somewhat 
plethoric, it is better to open a vein in the arm, which practice will 
not always arrest the progress of the inflammation, nor prevent 
the formation of pus, but will generally diminish the pain and 
tend greatly to limit the inflammatory focus. 

To return to the topical applications ; starch cataplasms, those 
made from rice farina are preferable to those of flaxseed, which 
when applied to the excited parts often give rise to eczema, during 
the short time they may remain. 

The parts should be examined for the purpose of detecting sup- 



180 VIDAL ON VENEREAL DISEASES. 

puration. Indeed, by early opening the abscesses, the focus of 
inflammation is considerably lessened, and the cavity of the abscess 
is placed in circumstances the most favorable for its obliteration ; 
the formation of burrowing sinuses and fistulas is thus likewise 
obviated. As a free incision is here of decided advantage when 
an abscess forms in the substance of the labia majora, I prefer to 
make the opening on the cutaneous rather than on the mucous 
surface. An opposite course would facilitate the passage of the 
vaginal secretions into the cavity of the abscess, which may prevent 
its closing, and thus expose the patient to the risk of purulent 
absorption. I have observed numerous facts which tend to cor- 
roborate this apprehension, and which cause me to insist on the 
importance of the precept here inculcated. 

Sometimes we are called upon too late ; the abscess is already 
very extensive, and the mucous membrane detached and attenu- 
ated ; the opening by the skin can no longer prevent the spontane- 
ous opening into the vagina. We must then not be contented with 
a free incision ; we must excise the detached mucous membrane, 
expose the bottom of the abscess, in fine, reduce all to one level, 
and destroy the cul-de-sac which may have formed. To effect this 
object it is necessary to excise not only the diseased mucous sur- 
face but a portion of the sound tissues. 

2. Vaginal-uterine Blennorrhagia. — In the treatment of this affec- 
tion injections are much employed. Eecently the tampon has been 
added to these means. But if the vaginitis is acute and compli- 
cated, with decided inflammatory reaction, we should first resort 
to antiphlogistics, direct and indirect. We may commence by 
taking blood from the arm ; the bowels should be kept free. De- 
mulcent drinks should be administered; warm baths have been 
recommended, and injections, which are to be used while the 
patient is bathing ; the injections may consist of a decoction of 
poppy heads, to which a little starch may be added. These decoc- 
tions should be employed warm. The active character of the 
inflammation may require the use of intra-vaginal cataplasms. 
For this purpose we may inject powdered starch or ground linseed 
of a half-solid consistence. These cataplasms cannot be employed 
except where the vulvar ring is very large. A syringe may be 
used from which the canula has been removed. 

When the inflammation has lost its intensity, and the reaction 
has subsided, we may resort to the use of astringent injections. I 
recommend the practitioner to commence with the following 
formula : 

B. Aq. §xx. 

Acet. Plumb, gr. xv. 
Sulph. Zinc. gr. xv. 

An injection morning and evening. 
We may afterwards employ the following : 



^ . Aq. Ros. | x. 

Nit. Argent, gr. iiss. 






BLENNORRHAGIA IN THE FEMALE. 181 

The strength of both these formulas may be gradually increased. 
I sometimes advise the alternation of these injections with the con- 
centrated decoction of the leaves of the walnut tree, either alone or 
combined with an equal portion of tar water. The injections are 
rendered more astringent in proportion to the chronic nature of 
the discharge. M. Eicord recommends the following formula : 

]J. Alum, 3 i. to 3 ii. 

Aq. Comm. (cold), g>i. 

Injections of acetate of lead should be preferred, when, to the other 
symptoms of vaginitis, are superadded that of pruritus of the geni- 
tal organs. If this does not exist, M. Eicord employs alum. In- 
jections of red wine, in which the red rose leaves have been boiled, 
are still recommended in chronic blennorrhagic vaginal discharges ; 
or the following formula may be employed : 

ty . Tannin pur. 3 iiss. 
Aq. S,i. 

When we wish to use the tampon after the injection, the fluid 
having come away, with the speculum we examine the deepest 
parts of the canal. Then, we introduce with the forceps rolls of 
soft charpie, or of carded cotton, until we form a perfect cylinder ; 
we then have a elytroid (sheath-like) tampon. Those who have 
followed for any length of time, the service of the Lourcine, can 
appreciate all the benefits to be derived from this practice. This 
method is attended with its inconveniences, as it requires to be re- 
newed daily, which is an annoyance both to the female and the 
practitioner. Hourmann preferred carded cotton, M. Eicord em- 
ploys dry charpie. According to the latter, cotton is a mechanical 
irritant, which even from its fineness, somewhat irritates the parts 
with which it comes in contact. Besides, it does not absorb the 
vaginal secretion equally well with the charpie. Charpie of lint 
is to be preferred. To each roll or pledget of charpie a thread 
should be attached one end of which should portrude externally, 
so as to facilitate its extraction. Should the vagnitis resist these 
means, we must then resort to the solid nitrate of silver. The 
neck of the uterus having been exposed by the speculum, with 
the caustic we whiten the whole vaginal mucous surface, as we 
withdraw the instrument, thus cauterizing it completely from 
behind forwards. 

A. Intra-vaginal Injections. — When there exists blennorrhagia 
of the cervix uteri, I employ chiefly intra-vaginal injections or 
douches. The fluid used consists of a very concentrated decoction 
of walnut leaves at the temperature of the room, no matter what 
the season of the year. I use a large enema s} r ringe ; the bivalve 
speculum is introduced, by which the cervix is seized and well ex- 
posed, the stream from the syringe is thrown upon this part with 
all the force which can be applied to the piston. Immediately 
afterwards, a strong tampon of charpie is placed on the neck of the 
uterus. A liquid of this kind thus injected produces as it were a 



182 VIDAL ON VENEREAL DISEASES. 

kind of compression on the neck of the uterus, and diminishes in 
temperature ; it acts beneficially also, "by its astringent qualities ; 
sometimes singular phenomena are developed. The cervix is ob- 
served to grow pale and to decrease in size ; and it seems to con- 
tract. These phenomena do not always occur, particularly that 
pertaining to its color : sometimes, however, I have seen the color 
increased during the injection. It has also happened, that when 
the uterus is relieved of the mucosities in its neck, at the moment 
that the injection strikes the latter part, new collections of mucus 
have been brought away, showing the retraction of which I have 
spoken, and perhaps even a kind of contraction of the womb. 

The female seldom experiences pain at the moment of the in- 
jection. After she has returned to her bed, she sometimes suffers 
from colicky pains, especially about the hypogastric and iliac re- 
gions. I have observed, that these pains are frequently felt about 
the time that the cure commences, and instead of being to me a 
source of anxiety, I regard them as a good omen. 

The following is worthy of note : when these injections were 
first employed, the number of cases in which colicky pains were 
felt was much more considerable than at the present day, notwith- 
standing they consisted of the same liquid, and that the same pro- 
ceeding, the same method of administration was adopted. This 
cannot be explained by the fact that females have now become ac- 
customed to these injections, for persons daily submit to them for 
the first time. Perhaps it would be more correct to say that the 
disposition of the uterine cavity (l 1 esprit de la salle) had become 
accustomed to their use. I shall again advert to this circumstance. 

These douches have frequently expedited in an extraordinary 
manner, the cure of certain engorgements of long standing, and 
have speedily produced the cicatrization of the most obstinate 
ulcerations. I saw at the Lourcine a woman set. forty ; there was 
a granular ulceration of the cervix uteri of some eight or ten lines • 
in extent in each direction, two or three injections reduced their 
diameter one-half. These injections have besides an advantage 
which no one can dispute ; they free the vagina and neck of the 
uterus from their mucosities and secretions which are more or less 
acrid, and which may exert a greater influence in perpetuating or 
even producing certain ulcerations than is generally supposed. 
The application of a tampon of charpie around the neck of the 
uterus, isolates the latter and thus promotes its cicatrization. The 
stream of the liquid injected, moreover, determines a momentary 
compression, which compression favors the resolution of all en- 
gorgements. 

These injections are employed twice a week ; they must not be 
used during the menstrual period, nor during for two days before 
or after this period. Pregnancy precludes their employment ; 
they should not be resorted to under four months from the time 
of labor or miscarriage. When the cervix, is very red and turgid, 
leeches applied to the arms, hip-baths, and general bathing, com- 
plete the treatment. During the days that the above injections are 
not used, the woman may continue her occupation, using herself 



BLEXXORRLTAGIA IN" THE FEMALE. 183 

the astringent injections whilst lying in the horizontal position 
with the pelvis raised as much as possible. 

B. Intra-uterine Injections. — The object of these is to introduce 
the medicated liquid not only into the neck but also into the cavity 
of the uterus. They are therefore employed when the blennor- 
rhagic affection has extended to the womb, and when it has as- 
sumed a chronic form, and has become a kind of uterine catarrh. 
These injections at first encountered strong opposition in the 
lecture room and in the journals ; then the question of priority was 
raised, showing at once their real success. I was compelled to 
disavow my claims to the invention of this method ; I claimed the 
merit only of retaining it on the therapeutics, and I even desig- 
nated several contemporary inventors of it, all for the sake of 
peace, but in vain ! More recently, I devised a much more simple 
plan to settle the question of priority ; I think that I have dis- 
covered that it is of Greek origin. I have availed myself of the 
historical knowledge and politeness of M. Daremberg, who has 
proved, by the most authentic quotations, that the women of ancient 
Greece were injected. But whenever reference has been made to the 
employment of injections by the Greeks, it has been asserted that 
they were Hmited to the vulva and the vagina. To this I called M. 
Daremberg's attention ; he has referred to me a very learned note on 
this historical point ; shovdng conclusively that Greek surgery, which, 
as is well known, was very bold, attacked even the uterine cavity, and 
that, in fact, intra-uterine injections were actually employed. 

The first objection to their use is the risk of peritonitis to which 
they expose the patient. Those who urge this must of course 
suppose that they pass from the cavity of the uterus to that of the 
peritoneum; the intra-uterine become therefore intra-abdominal 
injections ; the peritoneum becomes inflamed. I cannot notice all 
the various assertions that have been made on this topic, nor all 
the petty declamations to which it has given rise. I shall dwell 
only upon that which is of importance, and will commence by ap- 
pealing to experimental facts. I have instituted three series of 
experiments on the cadaver, to ascertain whether fluids injected 
into the cavity of the uterus, can reach the Fallopian tubes, and 
through them the peritoneum, and how it can thus happen : 

1st. Forced injections •; 2d, copious injections ; 3d, moderate in- 
jections. 1st. To administer the forced injections, such a syringe 
was employed as is used in our amphitheatres to inject the ar- 
teries ; the canula having been introduced within the neck, the 
latter was bound by a ligature around the tube so as to render 
impossible the return of the fluid injected. The piston was pushed 
with all the strength of a young and vigorous man. 

These forced and prolonged injections were made on uteri de- 
tached from the body, and which were not in the puerperal state, 
but belonging to women who had borne children. The result was 
that the liquid penetrated first the uterine vessels, and when these 
were emptied very slowly, it passes into the Fallopian tubes, and 
reaches their peritoneal extremity. The first series of experiments 
proved the extreme difficulty of penetrating into the tubes, even 



184 VIDAL Otf VENEREAL DISEASES. 

when great force was employed ; it proved the possibility of thus 
injecting the uterine veins. Such are the difficulties in causing 
the liquid to penetrate the Fallopian tubes, that if the cervix uteri 
be attached to the canula of the syringe by the ordinary proceed- 
ing, the injected fluid returns between the canula and the cervix. 
To avoid this reflux, it is necessary to pass, with a curved needle, 
a thread through the mouth of the uterus, so as to embrace a 
thinner layer of the cervix, which is then brought more closely in 
contact with the canula of the syringe. 

I need not here dwell upon all the results obtained by this first 
series of experiments, pertaining as they do not only to the ques- 
tion of therapeutics of which I treat, but also to that of the func- 
tions of the uterus, the history of its diseases, and of general thera- 
peutics. 

2d. In the second series of experiments, with the copious in- 
jections, a canula was introduced into the cervix having the dia- 
meter of a female sound ; the cervix was not fastened to the 
canula, and the injections were continued for a long time. Now 
the liquid was returned, passing between the instrument and the 
neck ; sometimes it reached, but slowly, the Fallopian tubes ; oc- 
casionally it penetrated the uterine vessels. 

This series furnished the greatest variety of results, as might 
have been anticipated from the structure of the uterus, its modi- 
fications by age, and the functions which it performs. Thus, if we 
inject the uterus of a female who has never borne children, we 
find the cervix uteri very small in diameter ; it is filled by the 
canula, and the fluid injected is returned into the vagina with more 
difficulty than when the same operation is performed on that of 
one who has been the mother of several children, and in whom the 
diameter of the uterine neck is greatly increased. The diameters 
of the orifices of the Fallopian tubes must also present marked dif- 
ferences arising from their greater or less permeability in different 
women. 

The size of the canula must therefore vary according to the 
state of the cervix ; a large quantity of liquids should not be in- 
jected, and the injection should not be prolonged. The two fol- 
lowing points should be particularly noted ; the liquid does not 
penetrate (if it does penetrate) the Fallopian tubes, except when a 
large quantity is used, and when the pressure on the piston has 
been long continued. In every instance it requires a Jong time to 
reach the Fallopian tubes. 

3d. In the moderate injections which constituted the third series 
of experiments, a syringe was selected such as is used for injecting 
the urethra; only five drachms were thrown into the womb. 
When pressed with no greater force than that ordinarily em- 
ployed in injecting the external auditory canal, the fluid did not 
reach the Fallopian tubes, but always returned into the vagina, 
passing between the canula and cervix. We need not be very 
strong vitalists to understand that the passage of a liquid into 
canals like the Fallopian tubes is still more impossible in the liv- 
ing than in the dead body. 



BLEMORRHAGIA IN THE FEMALE. 185 

Now, from a little reflection upon these experiments, and the 
unhappy results which have been attributed to them, we come to 
the conclusion, that if these unpleasant effects ever did follow, 
copious and forced injections must have been employed, and that 
had the contrary practice been pursued, the results would have 
been different. Those who preceded me used for their intra-uterine 
injections a clyster or a hydrocele syringe. Now, I maintain, that 
even with such instruments, strictly speaking no accidents oc- 
curred. I have been told that M. Eecamier washed the interior 
of the uterus with water without the least hesitation ; and my con- 
frere, Dr. Cardeilhac, assures me that he has passed and re-passed 
pints of sulphurous water into the uterus of one of his patients. 
He thus cured a purulent uterine catarrh, which had resisted many 
medications directed by respectable practitioners. 

We are taught by experiment that it is extremely difficult to 
penetrate the Fallopian tubes by injecting the uterus of a cadaver. 
In taking precaution to guard against such an accident in the liv- 
ing body, it would be most unfortunate to produce the contrary 
result, as it would be truly extraordinary if these tubes are more 
permeable in the living than in the dead female. 

The following is the method of proceeding : the bivalve specu- 
lum is first to be introduced, and the cervix rectified if any devia- 
tion exist. A silver or glass canula is then introduced within the 
neck, its diameter being fully one-third less than that of the or- 
dinary female sound. It is well to have still smaller canulas for 
females who have not borne children, and for maidens with narrow 
necks of the uterus. The importance of this precaution has been 
understood since I first made known my proceeding, a precaution 
which I have observed since my first experiments on the living 
subject. I desire thus to facilitate the return of the liquid injected. 

A small syringe, containing five drachms of liquid, is fitted to the 
canula, and the fluid is injected suddenly by a single effort. I for- 
merly used a decoction of walnut leaves, and a solution containing 
iodide of potassium, and of iodine. I now employ, most gener- 
ally, one and half grains of nitrate of silver in about three ounces 
of water. The strength may be increased ; only one drachm is to 
be injected at a single sitting. 

The quantity of liquid is so small, it is injected so suddenly, and 
with an instrument the extremity of which plays in the neck of 
the uterus, that we can perceive the impossibility of the smallest 
portion of it reaching the Fallopian tubes. What is to be appre- 
hended is, that it may not reach the uterine cavity. There are cases 
in which such a failure does take place. It occurs when a 
douche, a preparatory injection, has not been employed to remove 
the mucosities which collect, in the majority of cases, in the cer- 
vix, and which impede the introduction of the medicated fluids 
destined for the body of the uterus. But when this obstruction 
has been removed, and the cervix rectified, the injection is easy 
and complete. An injection may be used every morning ; seldom 
have I been compelled to resort to more than eight during the 
whole treatment. 



136 VIDAL ON VENEREAL DISEASES. 

In no instance should the injection be employed unless a satis- 
factory diagnosis has been made ; it must be borne in mind that 
we are treating a uterine catarrh which is protracted by a local 
cause. And as the uterus is an organ subject to great changes, as 
its condition at the approach of the menstrual period, as well as 
for a short time afterwards, differs from that in which it is found 
in a state of complete repose, and especially as its condition is 
modified after an accouchement or miscarriage, the use of the in- 
jections should be deferred as long as possible after the periods 
mentioned. Prudence also demands that we carefully examine 
the state of the other abdominal viscera. Without these precau- 
tions, certain phenomena, and even accidents, may occur, which 
may be attributed to the injections, but which, in reality, are due 
only to their untimely administration. 

Especially should we avoid injections after an accouchement, when 
the mouths of the uterine veins are still widely open. A case has 
been recorded in the journals, in which water, impregnated with 
chlorine, has been injected into a uterus under the circumstances 
just indicated ; of course accidents were not long in manifesting 
themselves. 

At the Lour cine, it was proposed to inject the uterus of a woman 
whose previous history was unknown. She had recently miscar- 
ried. The accidents which followed the injection were at first 
referred to the side of the belly ; they resembled the premonitory 
symptoms of a peritonitis, but assumed a singularly nervous char- 
acter. The lower extremities continued cold ; it was impossible 
to warm them ; in fine, a kind of intermittent fever set in, which 
I combated with the sulphate of quinine. This female remained 
in a painful rather than diseased state for nearly a month, but left 
the Lourcine cured of her uterine catarrh. I advise an examina- 
tion of the condition of the other abdominal viscera. If there be 
any irritation of the stomach, or intestines, if digestion be difficult, 
if there be diarrhoea, and especially if the large intestine are 
affected, we certainly should abstain from intra-uterine injections, 
or we should not resort to them until these complications have 
been removed. The following case shows the necessity of exam- 
ining into the condition of the intestinal canal before we employ 
them. 

A woman, get. 20, had long suffered from fluor alius ; an exam- 
ination with the speculum revealed a redness of the cervix ; a con- 
siderable quantity of dirty mucus issued from the womb. An in- 
jection of nitrate of silver was administered ; immediately after- 
wards, the patient was seized with colicky pains and chills ; she 
had six stools during the day, and there was febrile excitement. 
This woman, on being more closely questioned as to her previous 
history, stated that she was subject to attacks of colic ; that her 
digestion had been impaired : all of which she had concealed from 
the fear that she might be placed on an allowance. This patient, 
like the others, was cured after four injections — the three last hav- 
ing produced no colic. It is evident that the colicky pains, the 
diarrhoea, and trifling accidents which were observed in this 



BLEXNORRHAGIA IN THE FEMALE. 187 

woman after the injection, existed previously, though in a less 
decided form. All were exasperated by this trifling operation, 
and simple rest was sufficient for their disappearance. 

We here insert the particulars of a case which affords us another 
example of a cure, and which, at the same time, gives us an idea 
of the modifications of sensibility which are sometimes observed 
after these injections. We shall see that this state does not pro 
perly constitute an accident, but a phenomenon which can scarcely 
be called morbid. A female, set. twenty, who had never borne 
children, but who was troubled with fluor albas of very long stand 
ing, had an ulceration of the cervix uteri of a fungous aspect, 
about the size of a franc piece. Douches to the cervix with cauter 
ization, healed the ulceration. A muco-purulent discharge con- 
tinued from the os tincae. After a detergent injection, one of 
nitrate of silver was thrown into the uterus, and ten days after- 
wards the leucorrhoea had disappeared. In this case, the woman 
suffered pain immediately after the injection ; she compared them 
to those which precede the appearance of the menses ; they lasted 
during the whole day and the night following the operation. 
Twenty -four hours after the injection these pains ceased without 
the use of any medicine.* 

The abdominal pains which follow the injection are far from 
being constant. Most generally, the women who are injected at 
the hospitals seem indrfferent to what is being done ; it happens 
that, at the moment of the injection, the patients complain of a 
burning sensation which extends from the pelvis to the umbi lical 
region; it may also happen that this pain, or modified sensibility, 
is manifested in the iliac region. It is seldom that the pain ^ hich 
is felt at the moment of operating, even when the liquid penetrates 
the uterus, is of long duration. 

Some females, instead of suffering during the injection of the 
liquid, experience pains at the expiration of one or several hours ; 
sometimes, however, it is sooner felt. These pains seldom con- 
tinue twenty -four hours after the injection ; they generally sub- 
side in about three hours from their commencement. But, I 
repeat it, these colics are an exception to the general rule ; they 
occur scarcely in one out of ten who submit to this proceeding ; 
they subside spontaneously after a rest alone, and are not abridged 
by treatment. However, as females generally wish to have some- 
thing done, to satisfy the mind, we may prescribe some soothing 
potion. A still better course is, by encouraging words, to inspire 
confidence and to persuade the patient that she is sure to recover. 

Should the abdominal pain continue long after the injection, on 
questioning the patient closely, we shall find that this pain is an 
old affair, an ancient lesion. A woman whom I injected at the 
Lourcine complained for a long time of a pain in one of the iliac 
regions. I discovered, by questioning and repeated examinations 

* M. Callant, at that time my interne, has reported other cases of the kind. The 
subjects were females who were brought to the Midi, to make room at the St. 
Lizare for the insurgents wounded in June, 1S48. 



188 VLDAL ON VENEREAL DISEASES. 

with, the fingers, that in this patient there was a disease of the 
ovary which had been of long standing. 

I have said sufficient on the subject of these pains which have 
so greatly alarmed practitioners ; they are not produced by the 
irritation or inflammation of the peritoneum which had suffered 
from contact with an irritating fluid ; they are the result of uterine 
spasm, and to excite them, it is not always necessary to act di- 
rectly on the internal surface of the uterus, or to penetrate its 
cavity. The touch, cauterizations, douches to the cervix, simple 
vaginal injections of the most emollient nature, and those admin- 
istered by the female herself, when they scarcely pass beyond the 
vulvar ring, may all give rise to violent attacks of colic. One word 
farther in reference to one of my critics on this subject (an honest 
man, and acquainted with the diseases of the uterus). This es- 
teemed confrere observed formidable accidents follow a vaginal in- 
jection made by the patient herself. Think you that this observer 
wrote on the risks that may be apprehended from vaginal injec- 
tions ? By no means ; he composed a very fine article to prove from 
this case, that intra-uterine injections cannot be used without danger. 

3. Urethral Blennorrhagia. — The treatment of this disease in the 
female should be similar to that pursued in the male. Copaiba 
and cupebs should here be administered according to the formulas 
already mentioned. Thus, the electuary which I prescribe, copaiba 
one part, cubebs two parts, produces in the female effects anal- 
ogous to those obtained in the male. Only the dose should be 
more moderate, as it is easier to provoke disturbance of the di- 
gestive organs ; in them colic and diarrhoea are more frequently 
observed. 

As regards injections, I generally recommend those of an as- 
tringent character ; such as the sulphate of zinc and the acetate of 
lead dissolved in rose-water, or a solution of the nitrate of silver, 
but of a strength to cauterize the parts. If this effect be desired, 
it would be still better to employ the solid caustic, and the ordi- 
nary crayon of the pocket-case will suffice. 

In describing the accidents of blennorrhagia I have alluded to 
ovaritis and local peritonitis. When we suspect these complica- 
tions, we should resort to the local abstraction of blood, by the ap- 
plication of leeches to the affected parts ; recommend prolonged 
bathing, and rub in mercurial ointment over the regions to which 
the leeches have been applied. 



CHAPTER IY. 

BLENNORRHAGIA OF BOTH SEXES. 

The anus and the mouth have been observed to be the seat of 
blennorrhagia, both in the male and female. It is said that simi- 
lar discharges have been seen in the nose, the ears, and the infun- 



ANAL BLENNORRHAGIA. 189 

dibulum of the umbilicus ; this would be umbilical blennorrhagia. 
As I have no knowledge of these last-named varieties, I shall con- 
fine my observations to those which are seated in the anus and the 
mouth. 



SECTION I. 

ANAL BLENNORRHAGIA. 

Notwithstanding the frequency of unnatural intercourse, anal 
blennorrhagia is rare in comparison with the forms which we 
have already considered. The discharges observed in this part 
are for the most part consecutive, or proceed from mucous tuber- 
cles, and chancres. In the adult female, as well as the little girl, 
the muco-pus which sometimes escapes from the vulva, when the 
person is in the horizontal position, bathes the margin of the anus, 
and produces in this part a kind of blennorrhagia. When the dis- 
ease results from a suspicious connection, there is more or less 
deformity of the anus, its folds are effaced, and it assumes a more 
or less funnel-shaped form. The lining membrane is preternat- 
urally red, and it is rare that excoriations such as are observed in 
balanitis are not found. The surrounding skin is more or less 
heated, and exudes a moisture. The heat and pain are not con- 
fined to the anus, but extend to the rectum, at which part the pa- 
tient feels an uncomfortable sensation of weight. The discharge 
may be confined to the anus, the buttocks, or it may proceed from 
the rectum ; it is then more copious, and issues, from time to time, 
in streams, when the patient goes to stool, which is frequent, or 
during our examination ; occasionally it occurs during the emis- 
sion of the urine. By the touch, we detect an unnatural heat and 
turgescence. M. Eeynaud speaks of a speculum am which enables 
us to discover a redness of the mucous membrane which is contin- 
uous and uniform, or confined to particular points. In the treat- 
ment of this disease, the first thing to be observed is rest and 
cleanliness. A tampon of charpie should always be interposed 
between the buttocks, and we should begin with the use of emol- 
lient lotions, small enemas of marsh-mallow, and gentle laxatives. 
When the acute stage has passed, we may resort to lotions and 
injections of the acetate of lead. These may be followed by the 
decoction of rhatany. If these astringent injections do not suffice, 
we whiten the margin of the anus with a strong solution of the 
nitrate of silver, and we even inject a solution of the strength of 
from a grain to a grain and a half to eight ounces of water. A 
small glass syringe should be used like that employed for urethral 
injections. The administration of copaiba and cubebs by the mouth 
is now abandoned, for not only do they not produce any beneficial 
effect, but excite in the lower part of the rectum a mischievous 
irritation. 



190 VIDAL ON VENEREAL DISEASES. 

section n. 

BUCCAL BLENOEEHAGIA 

The following is the substance of my knowledge on this sub- 
ject. It is copied from the work of M. Baumes. 

" A short time since," says the physician of Lyons, " a laborer 
came to consult me : the left half of his lower lip was tumefied, 
red, hot, and painful, and there were several whitish granulations 
on its lining membrane, from which exuded a kind of purulent 
discharge. This membrane had precisely the aspect which the 
lining membrane of the neck of the uterus presents from blennor- 
rhagia. This person, who had been under treatment for more 
than a month and a half, informed me that this affection appeared 
some six or eight days after he had kissed the vulva of a female 
who, as he afterwards learned, was suffering from blennorrhagia. 
Notwithstanding all the soothing measures which up to this time 
have been employed, I have not been able to procure more than 
a trifling abatement of this specific inflammation, evidently deter- 
mined by blennorrhagic matter. 45 " 



CHAPTER Y. 

CHANCRE. 



The syphilitic virus, when brought into contact, under certain 
conditions, with the living tissues, produces two principal effects : 
1st, a form of inflammation, which is called blennorrhagia, from 
its product ; 2d, a form of ulceration, which is chancre. I have 
already traced the history of blennorrhagia ; chancre will form 
the subject of our present investigations. It is one of importance, 
and worthy of the reader's serious attention, particularly as cer- 
tain syphilographers regard chancre as the only medium by which 
syphilis can be admitted into the system, as the first condition and 
the sine qua non of the pox. Hence the doctrine, that without a 
chancre, there can he no pox. Facts and the most legitimate analogy 
show the error of this proposition. 

Seat — Chancre in the male generally occurs at the point of re- 
flection, the cul-de-sac of the prepuce, on its edge, whilst in the 
female, it is found external to the caruncula myrtiformes, near the 
fourchette. The cases are exceptional, where it is observed on 
the lips, the anus, the nipple, and at different points on the skin, 
especially that adjacent to the genital organs, where it is delicate, 
and has undergone a kind of mucous transformation. Mr. Mac- 

* Baumes, t. i., p. 210. 



CHANCRE. 191 

Carthy, whilst one of the internes at the Hopital du Midi, collected 
the statistics of chancres found in extraordinary situations. Of 
these one was observed in the nose, one on the gums, one on the 
tongue, three on the lips, two on the chin, four on the hand, two 
on the scrotum, fifteen on the anus, seventeen on the urethra, and 
three on the thigh.* 

Chancres are generally exposed to view, and are observed with- 
out difficulty : in this case,, they are called patent, to distinguish 
them from those more deeply seated in cavities and canals, which 
are termed concealed (larve). We may here remark, that this 
chancre larve has been' much abused. Its existence occasionally 
problematical, mysterious, and always difficult of detection, has 
singularly obscured the theories entertained on syphilis. More- 
over, there are concealed chancres which may be found, and there 
are those which are never discovered ; the latter are those which 
are especially abused. 

[M. Eicord, though he himself disavows any such claim, is erro- 
neously regarded by some as the discoverer of the chancre larve. 
It was distinctly noticed by Benjamin Bell {On Venereal, vol. 1st, 
p. 22), and by Mr. Judd (On Venereal, p. 186); but for the exag- 
gerated importance first attached to this concealed chancre, the 
entire credit is certainly due to M. Eicord. In his Letters, v., pp. 
34, 35, he states, that inoculation first and pathological anatomy 
afterwards, furnished him with incontestable proof of its existence, 
a fact which, as we have shown, was long before established. "We 
have also attempted to appreciate the value of this "incontestable" 
proof, and we think we have shown, even by his own experiments, 
that inoculation cannot be relied upon as the exclusive test for 
chancre, and as to his pathological evidence, the rebutting testi- 
mony of such men as MM. Velpeau, Yidal, and Dr. Gross, render 
it far from being incontestable. The specimens delineated in his 
Iconographie, and repeated in his Notes to Hunter, we believe are 
all that pathological anatomy has yet afforded him ; at least after a 
diligent search throughout his various works, we have been able 
to find no other. Chancres at the meatus, or an inch within the 
urethra, are not uncommon ; every practitioner must have seen 
numerous cases of the kind, but the deep-seated chancre, we think, 
has more frequently been presumed than proved to exist. Thus, 
Mr. Acton has reported (op. cit. pp. 300, 301, Am. ed.) a case of 
"indurated, urethral chancre, with secondary symptoms." No 
mention is made of the existence of bubo, " the necessary, inevi- 
table result" (Ricord, Lett, viii., p. 65), and "the almost absolutely 
certain result," according to Mr. Acton himself (op. cit. p. 285), 
of indurated urethral chancre. The secondary symptoms, too, 
consisted of rheumatism, an inflamed throat, and an herpetic or 
eczematous eruption, all of which circumstances render it proba- 
ble that the diagnosis made by Mr. Fichlin, of Cambridge, who 
treated the case prior to Mr. Acton, for blennorrhagia, was correct. 
Mr. Henry J. Johnson (op. cit.) remarks : "I have not myself wit- 

Thcse inaugurate, p. 13, et suiv. 



192 VIDAL ON VENEREAL DISEASES. 

nessed more than three unequivocal cases ; one at the Lock Hos- 
pital, one at St. George's, and one in private practice." These 
cases were presumed to be instances of urethral chancre from the 
fact that there was "a circular yet flattish induration/' about an 
inch or an inch and a half from the orifice, and that they were 
followed by secondary symptoms, which were cured by mercury. 
On almost the next page he has reported two cases of blennor- 
rhagia, followed by constitutional symptoms, and in these he does 
not even intimate his suspicion of the existence of a concealed 
chancre. Mr. Langston Parker (op. cit. pp. 101, 105), has detailed 
some cases of supposed urethral chancre, but in a letter dated May 
31st, 1853, with which he has politely favored us, he observes : 
" In the class of cases to which I have alluded, the existence of 
the chancre has been presumed, not demonstrated ;" and in the 
same letter he adds: "There do occur, from time to time, cases 
of secondary syphilis, in no way to be distinguished from those 
which succeed to an ordinary chancre, which own as their origin 
and source discharges from the urethra only, which discharges 
apparently in no way differ from common gonorrhoea, and an ex- 
amination of the urethra either during or after the disappearance 
of such discharges, no vestiges of contraction, cicatrix or stricture, 
or any condition incompatible with a healthy organization, can 
be detected. Surely, if a concealed, a urethral chancre had been 
present, its healing must have left some mark behind." Mr. 
Johnson, as we have seen, based his diagnosis upon the fact, that 
the disease was cured by mercury, and that there was induration 
in the canal. Mercury, we believe, is not at the present day re- 
garded as the test of syphilis, and induration, in itself, is a sign of 
no importance, as it may arise from abscesses, which are not un- 
common consequences of blennorrhagia. Although the connection 
between urethral abscesses and induration is distinctly noticed by 
M. Eicord, in his Lectures (Gazette des Hopitaux, 1847, p. 473), we 
find him in his Treatise inferring from the latter symptom alone 
the existence of urethral chancre, as in Case XX., p. 113, Am. ed., 
and others too numerous to mention. The actual state of the 
question has been admirably expressed by M. Bertherand, of 
Strasburgh, in his Prize Essay on Syphilis. "True," he remarks, 
" urethral chancres do exist, but it is no less true, that the number 
of those which have been recognized on the living, or detected 
after death, bears no proportion to the number of cases of blen- 
norrhagia which are followed by constitutional accidents." Such 
is the opinion of some of the most eminent surgeons of Great 
Britain, as we were personally assured on our recent visit to that 
country, and such, we doubt not, is the sentiment of the majority 
of our own most experienced practitioners. 

In adverting to the seat of chancres, we may also remark, that 
while non-specific ulcerations are exceeding common on the cer- 
vix uteri, chancres are rarely met with in this situation. This 
fact is particularly noticed by Dr. Henry Bennett in his excellent 
work on Inflammation of the Uterus, 3d ed., pp. 437, 451. It is 
also confirmed by Mr. Egan (op. cit. p. 125). He observes, that 



CHANCRE. 193 

during his attendance at the Lock Hospital for four years, he did 
not see a single example of the Hunterian chancre on the cervix 
uteri. "What renders the testimony of Mr. Egan on this point the 
more valuable, is the fact, that this hospital is exclusively for 
females.— G-. C. B.] 

It will be perceived that the differences of seat and of tissue give 
rise to differences of form, of aspect, and of other peculiarities 
which I shall be particular to indicate. 

The tegumentary surfaces to which the virus is applied may 
exist in two principal conditions : there may be a solution of con- 
tinuity, an ulceration or wound, or they may be intact. In the 
latter case, where the virus is applied on a surface more or less 
excited only, or where it is applied at the moment a solution of 
continuity of surface occurs, as for example, at the time of a rup- 
ture during coition, the same condition obtains as when a puncture 
is made for the purpose of inoculation. It is evident that when 
there is a solution of continuity, or when this occurs even at the 
moment of inoculation, certain local phenomena must always 
speedily become developed ; these may not appear, or if they do, 
appear at a later period, in .cases where the surface of the integu- 
ments remains intact. 

Characteristics of Chancre. — To facilitate our investigations three 
different stages or periods of chancre may be admitted ; that of the 
pustule, of ulceration, and of cicatrization ; in other words, the 
pustule of chancre, or properly speaking, chancre, is a suppurating 
wound. 

First Stage. — Pustule. — A distinction should always be made, 
and especially here, between experimental inoculation and physio- 
logical inoculation, in other words, from true contagion. Experi- 
mental inoculation will almost certainly produce the pustule ; it 
may be studied de visu. Physiological inoculation, on the contrary, 
will rarely afford us an opportunity of observing the pustule if it 
be observed at all. Let us consider the first effects of experimental 
inoculation. From the first day, after the insertion of a small 
quantity of pus taken from a chancre, a red point is noticed where 
the puncture is made. On the second day there is a slight eleva- 
tion, then a pimple. Soon a demi-turbid humor, then that which 
is completely turbid, fills the little cavity. From the third to the 
fourth day we find a vesicle, a pustule, or a bulla. At first there 
is a diffused redness around the puncture ; this redness becomes 
circumscribed in proportion to the development of the pustule ; an 
areola forms, furnishing us with evidence of the extent of skin 
about to be detached. If the pustule be not destroyed, on the 
sixth day its summit becomes flattened and is covered with a scab. 
Beneath the first scab another is seen still larger, and other layers 
exist, which together represent a truncated cone, surmounted by 
the first concretion. The surrounding tissues then become cede- 
matous and indurated. If the pustule now be opened, three days 
afterwards may be seen the signs of specific ulceration of chancre, 
as will be presently described. Such are the effects of experi- 
mental inoculation when the lancet has penetrated a little deeply, 

13 



194 VIDAL OX VENEREAL DISEASES. 

They commence at the moment of the puncture and occur without 
interruption. Let it be observed that there are here two things ; 
a puncture or a wound, and the insertion of a virus ; in other words 
a poisoning. This double action I will here merely mention ; its 
explanation will be attempted hereafter. So much for the experi- 
mental pustule, which is open to our view, as it may be made to 
form under our eyes. But observe, what is called the pustule of 
chancre does not always present the same characters ; it exists with 
or without a depression in its centre ; its contents are more or less 
turbid ; in fine, it presents the characters, more or less, of ecthyma, 
but these characters are not always identical ; sometimes it is even 
a pemphigoid bulla, the diameters of which exceed those of the 
ulceration. If there exist no pathogmonic form of eruption, neither 
is there a characteristic pustule. The eruption, moreover, does not 
always follow the progress which I have described. 

If the pustule arising from experimental inoculation, performed 
in a certain manner, is most generally of easy detection, such is not 
the case with that from physiological inoculation, from contagion. 
I have often directed the attention of students to this fact, during 
my gratuitous consultations at the Hopital du Midi: they may pass 
years in my wards without once meeting a case in which the 
pustule is observed to precede a chancre. Further, we have care- 
fully watched individuals affected with very inoculable chancres 
on the edge of the prepuce, by the side of which new chancres 
would form from day to day. They were attentively examined 
every morning, and the initial chancre was never seen ; in every 
instance the debut was an ulceration. It does not follow, however, 
that ulceration is always, absolutely always, the phenomenon first 
observed, for an abscess may precede a chancre. Thus, the syphi- 
litic virus may be absorbed by a mucous membrane, and be carried 
to a greater or less distance from the surface of application and 
absorption ; an abscess may be there produced, and its opening by 
ulceration will be nothing more nor less than chancre. Such is 
the condition of things in case of primary (d'emblee) syphilitic 
buboes. I am aware that practitioners have cauterized vesicles 
and pustules on their first appearance around the glans. But as 
these pimples were not pathognomonic, and as, according to these 
practitioners, we may confound the vesicles of acne and of herpes 
with the incipient pustule of chancre, I conclude that we cannot 
be sure that we destroy the latter by cauterization when it is prac- 
tised under the circumstances mentioned. 

I remark, in conclusion, that experimental inoculation may dis- 
tinctly produce the vesicle or pimple which precedes chancre ; that 
the form of this vesicle or pimple has nothing characteristic, and 
that experience has always shown me the chancre already entirely 
developed. Thus, I do not assert that chancre is always primary 
(d'emblee) ; I do not absolutely deny the existence of the pustule 
of chancre ; I assert that I have never observed it, and that those 
who suppose that they have, admit that it is difficult to distinguish 
it from certain other eruptions which are observed on the genital 
organs, hence I conclude that they have been mistaken. 






Fill 




' '0 ~~ 





< 






Pig 



X;//////;',/U^^ Anrtv /M^wakte c^/r^l 



CHANCRE. 195 

Second Stage. — Chancre. — This is the chancre, properly so called. 
The nicer is of a roundish form. (Fig. 1, Plate II. represents a 
follicular chancre on the glans, the circular form of which is almost 
geometrical ; the regularity of the chancre on the summit of the 
glans is interrupted by the meatus urinarius). Its base is irregular, 
appearing as if covered with little cells, and is of a yellowish gray 
color, more or less strongly marked. Its edges are perfectly per- 
pendicular (see Fig. 1), and more or less indented and detached. 
A violet red circle surrounds the ulcer, the breadth of which is in 
proportion to the detachment. Generally this ulceration involves 
the whole thickness of the integuments, and the tissues immedi- 
ately subjacent are more or less indurated and tumefied. Thus 
the base is more or less indurated, as are the edges of the ulcer ; 
the tumefaction of the latter causes them to be inverted, and the 
ulcer is then of an infundi-buliform shape. The ulcerated tissues 
are not entirely exposed ; but are covered by a pseudo-membranous 
layer, the formation and reproduction of which takes place with 
the greatest rapidity. This false membrane has been regarded as 
the matrix, the secreting organ of the virulent pus. Chancres are 
of various dimensions, from the puncture scarcely visible with the 
naked eye, to an ulceration of the diameter or even greater than 
that of a franc piece. 

They are not generally numerous ; they are two or three ; and 
when they exist in greater numbers, they are follicular, and 
are very near to each other, either on the glans, the prepuce or 
the vulva. The following are the most common characters of the 
regular chancre, that which is most frequently observed. But the 
ulceration is not always sufficiently deep to remove the whole 
thickness of the integuments, and its edges are not well defined. 
Occasionally the centre and borders of the chancre are found to 
be elevated so as to form a fungous projection ; it is then the raised 
(eleve) chancre, {ulcus elevatum.) The circular form is not always 
reproduced, and depends sometimes on the nature of the tissues 
involved ; thus, in the folds of the anus, we meet with the elongat- 
ed form, and the circle is more or less deformed when different 
kinds of tissue are invaded : on the edges of the glans and the 
prepuce chancre encroaches rapidly in the direction of the prepuce, 
where it finds least resistance, it is then no longer circular. When 
two adjacent chancres come in contact, they become one, which, 
however, is not of a circular form. 

At its commencement, chancre is sometimes the seat of a pruri- 
tus, which occasionally becomes very severe. It is the only modi- 
fication of sensation of which the patient complains. Sometimes 
there is a real pain, which may become so intense, as to prevent 
the patient from sleeping, and require a modification in our treat- 
ment : this phenomenon is observed when chancres are concealed 
beneath a prepuce with a narrow orifice, and in phagedenic 
chancres. But the pain is most frequently slight, and in some 
cases is felt only after some irritation, as from coition, which may 
lead to the detection of a chancre of the existence of which the pa- 
tient was before ignorant. 



196 VIDAL ON VENEREAL DISEASES. 

The surface of a chancre is bathed with pus more or less sanious, 
sometimes bloody, and mingled with organic detritus. This pus 
is alkaline, and contains animalculee which, however, is not a pe- 
cularitj of chancrous pus. What gives it its specific character, 
is the syphilitic virus, which is regarded as the product of the 
false membrane covering the tissues denuded by the ulceration. 
If the chancre is seated on a mucous membrane, if it be not ex- 
posed to the contact of the air, this pus remains in a fluid state ; 
but if seated on the skin, and exposed to the air, it concretes and 
the ulcer is covered with crusts. 

Chancre is generally of slow progress ; it lasts sometimes from a 
month to several years, and during this long period may retain its 
power of reproduction. M. Eicord cites in his lectures an instance 
where the duration of the chancre was seven years. He maintains 
that chancre is never spontaneously cured in less than a week. 

Third Stage. — Cicatrization. — When a chancre is about to heal, it 
passes into the condition of a wound, that is to say, its virulent 
membrane gives place to an inodular, cicatrizing membrane. 
Long since I established in my work on surgery* that the differ- 
ence between an ulcer and a wound consists in the difference of 
the membrane secreting the humor which covers the two solutions 
of continuity. When this cicatrizing membrane appears, the 
edges of the ulcer which are detached, sink, and approach the base, 
to which they unite. The inequalities of the base, the indentations 
of the borders disappear, and are replaced by fleshy granulations, 
resembling those in suppurating wounds. The violet red circle is 
succeeded by an areola of a pearly gray color. As the healing of 
the ulcer progresses, its circular form becomes changed, and angu- 
lar at several points of its circumference, because its edges are 
drawn inwards and in an unequal manner, by the inodular mem- 
brane, which has replaced the lardaceous layer already mentioned 
in treating of the progress of chancre. The cicatrix which suc- 
ceeds to chancre, like that of every solution of continuity with loss of 
substance, is shrivelled and depressed ; sometimes, instead of being 
depressed, it is, on the contrary, elevated, like a honey-comb. On 
the mucous membrane these marks at length completely disappear. 

Once the healing process commences, its progress is rapid, for it 
is now no longer that of a chancre but a wound. Cicatrization is 
not complete while there remains a single point of the grayish 
base. This point may extend, become developed, and the chancre 
itself be renewed, or, to speak more correctly, become enlarged 
and invade the cicatrized portion, and the adjacent integuments, 
which were not before attacked. But when the cicatrization has once 
covered the whole solution of continuity, a return is no longer pos- 
sible ; before another chancre can appear, there must be a new in- 
oculation. This is perfectly true, and accords with the opinions of 
M. Bicord. It is well to note particularly this point in the history 
of chancre, that it may not be forgotten when we come to decide 
upon the results of the inoculation of secondary accidents. 

* Vid. t. i., 3d ed., article Ulceration 



CHANCRE. 197 

Incubation. — Non-localization. — Two important questions here 
arise, of deep interest in a doctrinal and practical point of view. 
The first concerns the subject of incubation; in other words, it 
asks, if the syphilitic virus, when applied to our tissues, remains 
inert or in a dormant state, during a certain period, to be after- 
wards aroused and to produce effects which are externally appa- 
rent. I believe in incubation, that is to say, I believe that the 
virus may remain for some time a cause without effect, at least 
any appreciable effect. Hunter admits the incubation : he adds, 
even, that the interval is longer between the application of the 
virus and its external manifestations in chancre than in blennor- 
rhagia. M. Eicord here is opposed to Hunter ; he maintains that 
virulent pus, when applied to our tissues, produces an instantane- 
ous action, which remains local, three, four, five and even six days ; 
at which period, if with caustic we destroy the ulcer, general in- 
fection is prevented. M. Eicord invokes the aid of experiments 
and confounds its results, that is, inoculation by the lancet with 
physiological inoculation, or real contagion. From the puncture 
made by the impregnated lancet, and the pustule which follows, 
even to the formation and cicatrization of the chancre, he sees one 
uninterrupted series of phenomena. But by inoculation, by the 
wound made in the skin, we create a new surface, a traumatic sur- 
face which is not in the same condition as the normal surface on 
which pus is only deposited. The lancet produces necessarily 
traumatic phenomena, which ought to manifest themseves imme- 
diately, after which the manifestations of the virus appear, so that 
there is generally no interruption in the development of the local 
effects ; but these effects are not identical, they are of different na- 
tures ; one is a physical lesion, the other a specific affection ; occa- 
sionally we observe even a stationary period by which the two 
effects are separated. Further still, in consequence of certain very 
superficial inoculations, several days may elapse before any phe- 
nomena are produced. So much for the knowledge derived from 
experiment, when we know how to vary our proceedings. 

The advocates of incubation appeal to analogy and to carefully- 
observed facts. Thus, the greater number of morbid poisons re- 
main in the system for a certain length of time, without any evi- 
dent external manifestation ; they are there in a state of incuba- 
tion. Why may not the syphilitic virus obey the same law ? But 
facts favor this opinion still more than analogy. M. Baumes de- 
clared that a certain prostitute was affected with chancre ; not- 
withstanding the advice of this physician, this woman had con- 
nection with an individual who washed himself immediately. This 
person was subsequently attended by the same practitioner, who 
carefully watched the progress of his case ; it was not until the 
fifth day that a chancre, preceded by a kind of a little solid scale, 
appeared on the penis. I am acquainted with a precisely similar 
case. A young man had intercourse with a prostitute ; this 
woman was famous for her beauty. The young man informed a 
friend of his adventure. The latter who had already obtained a 
chancre from the same woman,, acquainted the young man with 



198 VIDAL ON VENEREAL DISEASES. 

the fact. The latter, very much frightened, applied to me. For 
four days, during which I attended him, I observed nothing. On 
the fifth day, a chancre appeared. Among the cases observed by 
M. de Castelneau, in which incubation preceded the development 
of the chancre, the majority of these patients were careful of their 
persons, and one of these was a confrere who was engaged in the 
study of venereal diseases. 

Now for the other question : Is chancre entirely a local affec- 
tion, or more properly speaking, are the effects of the virus at first 
confined to the locality to which the latter is applied ? How long 
does it remain in this locality ? On this subject we know no- 
thing, and experiment does not remove the uncertainty connected 
with these questions ; four, five and six days are mentioned, be- 
cause after the destruction of a chancre at these periods, by cau- 
terization and its conversion into a simple wound, cicatrization 
takes place, and the ulcer is not reproduced. Now there are 
chancres, which, even if destroyed at the earliest period mentioned 
in the above category, are nevertheless reproduced in the same 
place; of this we may be convinced by perusing the work of M. 
Eicord ; we shall there learn that this experiment has not always 
succeeded in completely destroying the effects of inoculation. Be- 
sides, the complete disappearance of a chancre is but a part of the 
proof of the limitation of the effects of the virus ; to be absolutely 
certain that its action had not extended further, that it has not in- 
fected the system, we must watch the patient for a long time, and 
see that the accidents do not afterward occur which are called con- 
stitutional. Now this counterproof, unlike the cliniqy,e, experi- 
ments have not furnished. Indeed, numerous observations prove 
that chancres which have speedily and entirely cicatrized, have 
after a time been followed by secondary accidents, and the work 
of M. Reynaud of Toulon, contains the report of a case by a phy- 
sician who saw on the genital organs two pustules which he 
thought would be followed by chancre. These pustules he imme- 
diately cauterized, yet secondary accidents were not prevented, 
although after the cauterization, the patient abstained from sex- 
ual intercourse. This case is corroborated by the experiments 
made by M. Reynaud, Professor at Alfort; he inoculated the 
virus of glanders ; the puncture was first cauterized at the end of 
three days, this was repeated two days, and lastly in twelve hours 
afterwards Now, in no instance was infection prevented. Again, 
M. Bousquet has cauterized the vaccine pustule on its first appear- 
ance, yet the subject was refractory to the influence of variola. M. 
Bousquet, after a discussion on the time required in vaccination to 
affect the system, expresses himself as follows: " For my own 
part, convinced as I am, there is actual infection during the period 
of incubation, I firmly believe that the person vaccinated has ob- 
tained the fullest influence of the matter a few hours after the 
pustules have appeared." (P. 529). The same author again re- 
marks : "With a double object in view I have opened pimples 
a short time after their appearance. I have then cauterized them 
deeply with caustic potash, so as to destroy the local action of the 



CHANCRE. 199 

vaccine matter. In the next place, I have re- vaccinated these same 
children, in whom it might be supposed that the vaccine matter 
had not entered the system, and no matter what precautions I 
took, the second operation always failed." (Bousquet, p. 534.) 
M. Hennequin, a physician who is deservedly so highly es- 
teemed, gives himself but little uneasiness about the number of 
pustules ; one suffices to inspire him with a feeling of perfect se- 
curity, and he permits any one to collect the vaccine matter. " As 
soon as, and even before the pimple appears, the prophylactic 
effect is produced." (Bousquet, p. 540.) Thus, in vaccination, the 
general, precedes the local action, or more properly speaking, the 
local is but the result of the general condition. The same is true 
in the case of the syphylitic virus : when chancre has formed, in- 
fection has already taken place. 

Admitting the localization of chancre, what are its limits ? Is 
it confined in its action to the ulcerated, indurated tissues, in fine, 
to the evident anatomical lesions, or does it extend to those which, 
at least apparently, retain their normal structure? ISTo positive 
answer has been given to these questions. But, mark it well ; 
those surgeons who at first cauterized the pustule with the nitrate 
of silver, now resort to a more powerful caustic, one which acts 
to a greater depth, viz. the Vienna paste. Whence the change ? 
Because the caustic first used failed in more than one instance. 
Moreover, the operation of circumcision, when chancre exists, has 
more than once furnished proof of the possible infection of tissues 
apparently sound, and at a certain distance from the chancre ; for 
example, I have sometimes excised almost an inch below chan- 
cres on the edge of the prepuce ; I have found the skin, mucous 
membrane, and cellular tissue entirely sound, and yet the wound 
became transformed into a vast chancre. 

[An instance of the latter kind has recently come under our 
own observation. If, therefore, parts apparently sound are in- 
fected, how can we know the extent to which cauterization should 
be carried in order to insure the patient from constitutional con- 
tamination ? M. Bicord states in his Letters (xxiv. p. 181) that 
by cauterizing twice the extent of the ulcer, he has always suc- 
ceeded. From the conflicting statements of this surgeon, how- 
ever, contained in the Letter to which we have just referred, and 
his Treatise (Ed. p. 221), we are compelled to doubt this constant 
success. In his Treatise he speaks of his constant success with the 
nitrate of silver ; in the above Letter he asserts that cauterization 
with the nitrate of silver almost always fails ! His own testimony 
is equally contradictory as to the influence of the extent and du- 
ration of the ulceration upon constitutional infection. In his first 
and twenty-eighth Letters, pp. 8, 208, he states that constitutional 
infection bears no proportion to the seat, number, extent, nor abso- 
lute duration of a chancre ; that a small chancre exposes equally 
with a large one to the risk of general infection, &c. In his twenty- 
fourth Letter, however (p. 181), he asserts that the sphere of viru- 
lent activity is in proportion to the extent and duration of the ul- 
ceration I In his communication, also, to the Academy of Medi- 



200 VIDAL ON VENEREAL DISEASES. 

cine, July 27th, 1852 (De la Syphilization, &c., p. 74,) he distinctly 
declares that a large chancre produces a more extensive infection 
than a smaller, as the extension of its borders constitutes so many 
successive inoculations ! — Gk C. B.] 

My opinion on the subject of the incubation, and the localiza- 
tion of the effects of the syphilitic virus, may be thus expressed : 
believing in the physiological absorption of the virus ; in othe^ 
words, absorption without previous ulceration at the point to which 
the virus is applied, I should be inclined to admit the doctrine of 
incubation, and facts moreover show that this incubation is real. 
In the localization of chancre I do not believe. I do not think 
that for a certain period the effects of the virus are limited to the 
narrow sphere of a chancre. I believe that a recently-developed 
chancre, which already secretes a virus capable of inoculation, will 
at the same time produce that which is capable of absorption. In 
certain conditions of the surface, when it is much excited, or there is 
an excoriation, a wound, or puncture made for experimental inocula- 
tion, local phenomena are speedily develojoed, which are represented 
by a pustule or otherwise. But these local do not prevent the 
general effects ; they may occur simultaneously. The physician 
to whom allusion is made in the work of M. Reynaud, and who 
witnessed the development of the pustules, was both inoculated 
and affected at the same time, for the destruction of the local 
effects, the pustules, did not prevent the occurrence of constitu- 
tional accidents. Under certain circumstances, on the contrary, 
the virus is absorbed without producing at first a local effect, and 
the latter is produced by a reaction (contre-coup), that is, after a 
period of incubation of a portion of the virus. 

Varieties. — Thus far we have only considered the so-called regu- 
lar chancre. I have pointed out the characters by which it may 
be distinguished. I have also alluded to the differences depend- 
ing on the seat, and the nature of the tissues affected, differences 
which may mask the ulceration, and change its form. I now pro- 
ceed to point out the varieties, the deviations of the primary ulcer, 
which are sufficiently marked to be separately described, and this 
for the sake only of their study. 

It is during the progress of venereal ulcerations that their most 
remarkable deviations are observed, and chancres may so differ in 
form as to constitute varieties. 

1. Phagedenic Chancre. — This is a repetition of terms, for the 
word chancre signifies a gnawing corroding affection ; but chancre 
has its conventional limits, which, once broken, go to establish the 
varieties now to be studied. The progress of the phagedenic af- 
fection is not always uniform, and its characters may vary, by 
which sub-varieties are constituted. Thus, there are chancres, 
the ravages of which extend almost equally around the centre, 
which is their starting point ; when cicatrization commences, it is 
observed equally at all these points. On the other hand, there are 
phagedenic chancres which describe circles and demi-circles, which 
festoon a region, which have, in fine, a serpiginous progress ; we then 
see cicatrization going on at one point, and the ulceration at another. 



CHANCRE. 201 

[The phagedenic primary ulcer has been observed by Messrs. 
Acton and Egan to occur in the following proportions : in ex- 
amining M. Eicord's wards for this purpose, Sept. 20th, 1847, he 
found but 5 in 112 cases of primary sores, and Mr. Egan (op. cit. 
p. 49) states, that out of upwards of 300 cases of primary infection, 
he met with but ten which assumed the phagedenic character 
from the commencement. "We are satisfied, that, like hospital 
gangrene, this form of ulcer is met with much more frequently 
at some seasons than at others. Years may pass, and in the same 
hospital but few cases will occur ; then, of a sudden, it shall rage 
with much severity. This was noticed by Benjamin Bell. In his 
work on the venereal, 2d vol. p. 22, he remarks that he met with 
more instances of this phagedenic chancre than he had seen for 
several years before, and in four of them the affection was traced 
to the same woman, a fact tending decidedly to corroborate the 
doctrine of a plurality of poisons. It was formerly much more 
prevalent in this country than at present. In 1818-19, '20, and 
again in 1827-28, it prevailed to a considerable extent in Philadel- 
phia (M'Clellan's Surgery, p. 239.)— G. C. B.] 

The two first sub-varieties which I shall describe depend more 
particularly upon gangrene,' — the first to ordinary gangrene, the 
second to what is called hospital gangrene. 

a. The first sub-variety is termed gangrenous chancre. Ulcera- 
tion being in my opinion but a form of gangrene, I regard all 
chancres as gangrenous ; but in ordinary chancre, the gangrene is 
molecular, whilst in the so-called gangrenous chancre, there are 
notable portions of tissue of greater or less extent involved ; for 
example, fragments of the prepuce, a part of the penis, &c. ; it is 
therefore the gangrene of small portions (parcelldire). 

At present I have in my wards six patients affected with gan- 
grenous chancre. This variety is more frequently observed in sub- 
jects in whom congenital phimosis exists, or who, although able to 
uncover the glans, have nevertheless a preternaturally elongated 
prepuce. As the glans resists the effects of gangrene more than the 
prepuce, the latter becomes more particularly affected. Generally 
it is on the dorsum of the penis that we find the prepuce per- 
forated to a greater or less extent. The glans sometimes escapes 
by this opening ; the upper part of the prepuce is forced down- 
wards, and the penis assumes a bifid form. Sometimes only a 
small portion of the prepuce, connected with the frenum, is left. 
Finally, the gangrene may effect a complete circumcision, de- 
stroying the whole prepuce. The glans is generally invaded to a 
greater or less extent. I have observed exceptional cases, in 
which the glans alone was attacked, appearing like a little pimple 
on the end of the urethra. The prepuce remained intact. It hap- 
pens also that the penis is sometimes completely carried away ; 
prepuce, glans, cavernous body, urethra, all are swept by the gan- 
grene, which has therefore performed a kind of amputation. At 
present there is a person in niy ward (No. 9) whose penis is de- 
tached a little above the scrotum. 

Six subjects which have come under my observation, had a 



202 VIDAL ON VEKEREAL DISEASES. 

good constitution : they had been guilty of excessive indulgence 
during hot weather. One had a high fever and delirium before 
the gangrene was established. During the formation of the eschar 
the patient generally suffers acute pain, especially if the glans be 
the part affected ; the separation of the eschar is rapid, and the 
wound which follows is speedily cicatrized. I have not observed 
consecutive accidents in patients who have had gangrenous chan- 
cres with considerable loss of substance of the prepuce, although 
some of them remained two months under my care. It is said 
that gangrene is the result of the excessive inflammation of the 
tissues surrounding the chancre, and that this gangrene, by re- 
moving the entire ulceration, prevents general infection. But be- 
fore the gangrene is developed, the virus may already have entered 
the circulation, as happens in cases where the gangrene is pro- 
duced by caustics, when the virus may penetrate the system. 

b. The second sub-variety is called the diptheritic or pultaceous 
chancre. It is most frequently observed in feeble and aged sub- 
jects, in children who are placed in unfavorable hygienic con- 
ditions, and in persons debilitated by a bad regimen, or an im- 
properly-managed mercurial treatment. 

This form of ulceration bears the most striking analogy to 
hospital gangrene ; the chancre is in fact complicated with this 
kind of gangrene. The base of the ulcer is yellow, with points 
more deeply colored, and which bleed ; it is tomentose, fretted and 
jagged; the surrounding tissues and the base are thickened and 
indurated. The skin is of a vinous red color, and detached, for 
the destruction of the cellular tissue precedes that of the integu- 
ments. The skin afterwards subsides, becomes perforated, and 
finally suffers the fate of the cellular tissue. The parts in which 
the purulent or rather sanious matter accumulates, are those in 
which the destruction is most complete ; these become distended 
with organic detritus. I have seen a pultaceous chancre of the 
prepuce destroy the entire tegumentary covering of the penis even 
in the scrotum. If we attempt to wash the base of such an ulcer, 
it bleeds, and we remove but the portions of false membrane by 
which it is covered. This kind of coating is immediately re- 
produced. 

The patient experiences hot and stinging sensations with severe 
pruritus : he is, as it were, conscious of the destruction going on 
within him. When the nerves become exposed by the gangrene, 
then the patient suffers all the tortures of neuralgia. There is a 
low grade of fever, and an emaciation follows which ruins the 
constitution. The patient's system sometimes resists until entire 
regions are made bare, as for example, the whole inguinal region, 
a part of the thigh, and sometimes of both thighs. An aged pa- 
tient, a septuagenarian, was lately brought in a desperate state to 
the Hopital du Midi, where he died from consumption, produced 
by phagedenic chancres, which had destroyed the greater part of 
the penis, and transformed the two inguinal regions into enormous 
caverns. The autopsy as noted by my former interne, M. Pellagot, 
revealed the following : I transcribe it fully, because autopsies of 



CHANCRE. 203 

this kind are rare, and becanse a morbid condition of the thoracic 
canal was here found, which I believe has not before been noted. 
The reader will perhaps be astonished that the lungs were found 
perfectly sound, and this too, with a very evident tubercular con- 
dition of the most important portion of the Lymphatic system. 

" But a few traces of the penis, the starting point of the chancre, 
were left. In the left inguinal region was an ulceration extending 
to the femoral aponeurosis, which had destroyed the superficial 
fascia and the ganglia without touching the vessels. The right 
inguinal region was the seat of a vast ulceration or gangrenous 
cavern, extending from Poupart's ligament, its superior boundary, 
to the junction of the superior with the middle third of the thigh. 
The tissues were entirely destroyed and the vessels were exposed. 
The crural nerve was dissected even to its origin. The arterial 
tunics were thickened but not yet ulcerated. Yery extensive 
coagula were found in the crural vein, which was the seat of some 
inflammation. The internal saphena was destroyed as high as its 
origin. Adherent coagula were here found, which explained 
the absence of hemorrhage during life. The stomach and intes- 
tines presented nothing abnormal, with the exception of a slight 
redness, and hardened faces in the cavity of the latter. Well- 
organized layers of fibrin adhered to, and were interwoven with, 
the columnia of the ventricles of the heart. The cardiac muscu- 
lar fibres were a little pale and discolored, but not softened. There 
was a milky layer on the pericardiac surface. A slight hypostatic 
engorgement of the convex border of both lungs were discovered, 
but the rest of these organs crepitated perfectly, and presented 
neither purulent foci nor indurated nuclei. Lymphatic system. 
Both iliac fossa were the seat of a peculiar ulceration. The 
cellular tissue of these regions, especially that of the right side, 
was indurated, and studded with tumefied lymphatic ganglia of 
which some were filled with pus. These numerous masses of 
ganglia surrounded the internal iliac arteries and the termination 
of the aorta ; they also embraced the thoracic canal as far as its 
termination, reaching even to the left subclavian vein. The 
thoracic canal itself presented at long intervals considerable no- 
dosities resembling in form the beads of a chaplet. On incising these 
nodosities, there were found within the canal lymphatic deposits 
resembling ganglia. The greater number of these, hard at their 
circumference, were soft in the centre, and had suppurated like 
those of the iliac fossa. The osseous system presented nothing 
abnormal." 

The third sub-variety is the serpiginous chancre. Instead of 
starting from a single point like the preceding variety, and ex- 
tending more or less circularly, encroaching upon the tissues 
which offer the least resistance, the serpiginous chancre follows 
circles, or portions of circles, more or less regular, like certain 
consecutive ulcerations, as the serpiginous syphilida. "When 
cicatrization resists its progress on the one part, the chancre gains 
on the other. It may then be compared to a creeping plant. 
Sometimes cicatrization begins in the centre, and the ulceration is 



204 YIDAL ON VENEREAL DISEASES. 

observed at its circumference ; so that, in the middle of the ulcer, 
there is an modular disk, which always increases in size, whilst 
the borders become likewise more excavated and enlarged. 

The serpiginous chancre most frequently coincides with the 
tubercular diathesis and the dartrous vice. Sometimes the tuber- 
cular condition is not manifested among the antecedents of the 
serpiginous chancre, but only at an advanced period of the disease. 
I have witnessed this peculiarity in a patient under my care in 
"Ward No. 11. Occasionally the herpetic vice is hereditary. In 
one subject, it was not manifested by any particular symptoms, 
but became developed during the progress of the chancre, which, 
together with its form, it modified, &c. The scorbutic vice like- 
wise plays an important part in this singular variety of phagedenic 
ulceration. 

In these three sub-varieties, two are clearly capable of inocula- 
tion, viz., the diphtheritic and the serpiginous ; such, however, is 
not the case with the gangrenous chancre. According to M. Ki- 
cord, the latter does not produce secondary symptoms, and is 
rarely followed by buboes ; and when these occur, they subside 
and disappear even before the gangrene. The consecutive acci- 
dents of the two other sub-varieties have not the grave character 
of the chancre by which they are produced. Everything here 
depends upon the condition of the patient, of his constitution, and 
the diseases from which he is suffering at the time of his infection. 

2. Indurated Chancre. — Induration, in other words that deposi- 
tion of plastic lymph beneath and around the ulcer, which gives 
to chancre its peculiarity, is an inseparable feature in this disease : 
according to Babington, it even preceds the ulceration. Accord- 
ing to this writer, all chancres are indurated. Thus expressed, 
this proposition is admissible, and I am disposed to accept and 
defend it. I believe, in fact, that the specific ulceration called 
chancre is, in all cases, more or less indurated. This opinion has 
always prevailed : to the idea of chancre, has always been added 
that of more or less induration ; thus Astruc, who gives a sum- 
mary of the views entertained by every writer on syphilis who 
had preceded him, defines chancre a small, round, and callous 
ulcer* 

"With Hunter, induration is the rule. Babington maintains that 
Hunter's description applies to 49 out of 50 cases. We give Hun- 
ter's own words: "A thickening of the part comes on, which at 
first, and while of the true venereal kind, is very circumscribed, 
not diffusing itself gradually and imperceptibly into the surround- 
ing parts, but terminating rather abruptly" (p. 403, 2d ed. Bicord^s 
Hunter). It is the classic induration, the Hunterian chancre. In 
a note, Babington adds: "The character of primary venereal 
infection is, essentially, induration passing afterwards into ulcera- 
tion" (he. cit. p. 409). I should add that between this induration 
so concisely described by Hunter, and this base which, according 
to Benjamin Bell, resembles a split dry pea, there are many de- 

* Astruc, t. iii., p. 338. 



CHANCRE. 205 

grees which, when carefully observed, go to establish the relations 
of the ordinary regular chancre with the indurated chancre. I 
will not, with Babington, assert that induration precedes ulcera- 
tion ; nor will I admit, with others, that induration is consecutive ; 
I believe that both these conditions may occur simultaneously : 
whilst nature affects a diaeresis, it also produces a synthesis, it 
condenses the tissues, or creates a fibro-plastic tissue beneath and 
around the ulceration. One cause of deception, and the admission 
of non-indurated for the really indurated chancres, is that some- 
times the base alone is indurated, and the edges readily subside ; 
or the edges alone are indurated, while the base does not present 
a marked consistence, or the inflammation which surrounds the 
chancre is sufficiently intense to conceal the induration. There- 
fore, chancre is always indurated to a certain extent. This is the 
opinion which I profess. The proof of it is, that allusion is made 
to hard, hardened chancres, an expression which is diminutive of 
indurated chancres. This truth, once understood, singularly sim- 
plifies the relations of chancre to the constitutional affections. 

The following are the characters of the indurated chancre, ac- 
cording to those who would at the present day recognize in it a 
separate form of chancre. The induration represents a demi- 
sphere, or the base of a split pea, in the language of Benjamin Bell. 
This induration, this peculiar basis of the ulcer, depends upon an 
effusion of plastic lymph, and has almost a fibro-cartilaginous con- 
sistence (vide Plate 2, Fig. 3), and a certain elasticity, which once 
observed, is not soon forgotten. The surrounding tissues retain 
their normal color and consistence, participating not the least in 
the chancrous induration which ceases abruptly, the boundary of 
which is a projecting border, which sometimes curls over under 
the corona glandis. A perfect specimen of this chancre is repre- 
sented in the figure already mentioned; cicatrization is taking 
place ; it is not entirely round, but the cartilaginous character of 
the border is clearly recognized by the white reflection. The sub- 
ject of this chancre was under the care of M. Puche. A roseola 
had already appeared at the base of the chest, in other words, the 
patient's system was completely infected. 

The indurated chancre secretes little matter ; it is not always of 
a circular form, occasionally a portion of its border projects and 
forms a crest. According to M. Eicord, chancre does not become 
indurated until the fifth day, generally not until after the first 
week. This form of chancre is observed more frequently in the 
male than the female. It may be complicated with inflammation, 
and even with gangrene. When the latter occurs, it is central : 
the inflammation appears to have invaded the indurated portion ; 
it seems to produce strangulation, and, like all inflammations of 
this kind, when left to itself, it terminates by gangrene. Thus 
we observe eschars occurring in indurated chancre, which sooner 
or later separate. Fig. 2, plate 2, represents an indurated chancre 
which has become transformed into a large eschar, which transform- 
ation was accompanied with severe pain. It will be seen that a 
portion of the glans has been removed, and the corpus cavernosum 



206 VIDAL ON VENEREAL DISEASES. 

exposed ; tether, after the separation of the eschar, cicatrization 
has commenced, and it is at this stage that the sketch was taken. 
The patient was in Ward No. 11, of my service, at the Hopital du 
Midi. 

With the history of chancre have been connected questions still 
involved in obscurity. By some, it is maintained that the indur- 
ated chancre alone is followed by syphilis, or that it is the start- 
ing point of the constitutional disease ; others believe that it is 
principally this form of chancre which produces the pox. As I 
have shown that chancre is always more or less indurated, it is 
unnecessary to refute this proposition. Then again it is asserted, 
that the chancre must be strongly indurated, to be followed by 
consecutive accidents. To this I reply, that these accidents have 
been known to follow chancres but moderately indurated, and the 
speedy cicatrization of those which were regarded as non-indurated. 
Moreover, those who make of the indurated chancre a separate 
variety, admit that induration is not generally established until 
after the first week. Now, during this period, infection may take 
place, and generally it does not wait this term. In my opinion, 
instead of framing the question thus : Can the indurated chancre 
alone produce secondary accidents, or does it produce them more 
frequently than the other varieties of chancre? I would rather 
ask, What connection exists between the indurated chancre and the 
constitutional disease ? Certain it is, that the general state of the 
system modifies the form of the chancre, and wherever we find an 
action which can be called syphilitic, the reaction must be greater. 
For example, when chancre is obstinate, when, from being moder- 
ately, it becomes much indurated, and seems to constitute a separ- 
ate variety, I believe that the syphilitic virus has then for some 
time already infected the system. The cause of the constitutional 
disease therefore exists, and the system is already infected. This 
degree of induration proves only that the diathesis is established : 
for the indurated chancre is really a consecutive accident, an ex- 
pression of confirmed pox. But the effect of the diathesis may be 
confined to this point ; in other words, we may have an indurated 
chancre, without any other manifestation of the general infection. 

[We are satisfied that the majority of practitioners do not coin- 
cide with the views of M. Kicord, who would restrict constitu- 
tional infection to the true indurated chancre. Our own observa- 
tion has taught us the correctness of the doctrine inculcated by 
Mr. Lane, in his valuable lectures published in the London Lancet 
for 1841-2, vol. ii. p. 591. He thus observes : " The practical 
inference I wish you to draw from these remarks is, that a mere 
principle, an excoriation, a vesicle, a pustule, a minute ulcer, one 
covered with a scab or not, a superficial ulcer, a raised ulcer, a 
deep one, one with or without induration, a spreading ulcer, 
phagedenic or sloughing, a stationary one, a cicatrizing ulcer, 
ulcers varying in form, in color, size, or number, may contain, or 
have contained, the syphilitic virus, and, consequently, may be 
followed by the secondary or constitutional disease." Those en- 
gaged in the study of syphilis cannot do better than to consult 



CHANCRE. 207 

these lectures by Mr. Lane, whose connection with the Lock Hos- 
pital, London, and whose vast experience in the treatment oi 
syphilis, render his remarks of great practical value. — Gr. C. B.] 

Is it necessary to reply to the question : Can a patient have 
several different attacks of indurated chancre ? Is it true that a 
chancre, becoming developed after the indurated, will assume this 
form ? But this is a complicated question, since all chancres are 
more or less indurated ; or, if we would speak of a strongly -indur- 
ated chancre, the expression of the syphilitic diathesis, the ques- 
tion becomes involved into this : Can a person have the pox more 
than once ? Experiment has already replied to this in the affirm- 
ative ; and the case observed by M. Boully, which we have quoted, 
leaves no doubt on this subject. I shall return to this question in 
treating of the consecutive venereal accidents. The indolent bubo, 
which should be the inevitable accompaniment of the indurated 
chancre, will be considered in the next chapter. 

3d. The raised chancre {ulcus elevatum). — The base of this chancre 
is raised by a kind of vegetation of the form of a round or oval 
basin, of a fungous nature, and more or less raised above the skin. 
These chancres occur frequently on the edge of the prepuce ; they 
furnish a sero-purulent matter, are generally not painful, and their 
borders and base are but little indurated. When cicatrization 
takes place, it still remains for some time above the level of the 
skin, a flattened and whitened projection, which is slow in disap- 
pearing ; the cicatrix, after awhile, sinks to a level with the sur- 
rounding parts. Too much importance has been given to this 
form, not only in making of it a separate variety, but as giving 
rise to a peculiar kind of constitutional disease. Fig. 1, plate 2, 
represents three raised chancres on the prepuce, and two ordinary 
chancres on the glans. The latter are the result of inoculation 
with the matter from the former ; they are therefore all produced 
by the same virus ; only those on the prepuce assume a fungous 
character, on account of the yielding of the loose cellular tissue 
of the part, which cannot occur on the glans. The subject of these 
chancres was in Ward 10, bed No. 13. 

Now, if we reflect on the different forms of chancre, which I 
have described under the head of varieties, we find that they are 
the result of complications. Thus, the first variety is complicated 
with gangrene ; another form, the diphtheritic, with hospital gan- 
grene, whilst the indurated serpiginous variety is connected with 
the tubercular diathesis. I believe that the raised chancre depends 
greatly on the locality ; it assumes this form when it is seated on 
loose cellular tissue, as on the prepuce. I believe that this is the 
most important practical view of the subject, in our investigations 
into the causes of the deviations in the form of chancrous ulcers. 

Diagnosis. — In the majority of cases the diagnosis of chancre is 
not difficult. The practitioner who possesses a tact for observa- 
tion, need but glance at an ulcer to detect its syphilitic nature. I 
have already described chancre with sufficient minuteness to aid 
the young practitioner in forming a diagnosis. A round ulcer 
with edges perpendicular and a little detached from the v 



208 YIDAL Otf vejst:real diseases. 

gray or yellowish, base, covered with little cells, induration, a 
violet-red circle, located on a part concerned in sexual intercourse, 
suspicious connection : these sum up the characters and circum- 
stances by which a true diagnosis may be established. But these 
elements do not always fully exist, and they are sometimes modi- 
fied and defaced : thus, both form and color may be changed, and 
the ulcer may be seated in an unaccustomed locality. Interest, 
false modesty, may lead to the concealment, or a misrepresentation 
of the antecedent circumstances. The uniform test with M. Eicord 
is the matter secreted by the ulcer : if, on inoculation, this pus 
produces a chancre, its syphilitic character is established, and the 
other elements of diagnosis are of no value. 

But, as there are chancres, the pus of which cannot always be 
inoculated, this test cannot always be trusted ; and these are the 
chancres which present the most difficulties, and in the diagnosis 
of which inoculation would therefore be the most useful ! Such, 
indeed, are the chancres of unnatural shape, caused by cicatrization 
or some other complication, such the deep-seated chancres, the 
chancres larves, for the diagnosis of which inoculation should be 
so important, yet these are precisely the cases in which it fails. 
(See my remarks on the nature of blennorrhagia.) As to other 
chancres, those which are open to view, and still progressing, 
unmodified by the process of cicatrization, inoculation is here use- 
less ; it is even dangerous. Thus, in doubtful cases, when it is of 
importance to decide whether an ulcer is or is not a chancre, inocu- 
lation is insufficient. The differential diagnosis of chancre, in 
other words the distinction between primitive and consecutive 
ulceration cannot be established by inoculation, since I have 
demonstrated that both of these forms of ulceration may be inocu- 
lated. We must, therefore, in obscure cases, have an especial 
regard for clinical diagnosis ; we must carefully collect the antece- 
dent circumstances and inform ourselves of the commencement of 
the progress of the ulceration, minutely note all the characters of 
the lesion, and pay especial attention to those furnished by the tis- 
sues in which the ulcer is seated. If there be an induration, and 
if the other circumstances are in favor, we may regard it as a 
syphilitic ulceration ; for, in my opinion, every syphilitic ulcera- 
tion is accompanied with induration. There are cases in which 
this is the only character on which we can fix: indeed, certain 
chancres of the fossa navicularis, or concealed beneath a narrow 
prepuce, are only discovered by the touch, which detects the indu- 
rated points. True there are other kinds of ulceration which are 
indurated, but then the concomitant circumstances are different, 
their progress is not the same, and they lack the circumstances 
that precede venereal diseases. Thus, cancerous ulcers have a more 
or less indurated base, but their entire history shows no connection 
with chancre. Sometimes it must be acknowledged, that notwith- 
standing the most minute attention to details, and the greatest 
power of grouping them in one assemblage which shall represent 
their diagnosis, the latter still remains obscure, and our doubts are 
removed only by the appearance of certain consecutive accidents. 



CHANCRE. 209 

The young practitioner should therefore be very cautious in an- 
nouncing his opinion, especially in courts of justice. It is import- 
ant that he be forewarned not only that observation may lead to 
mistakes, but that he should also understand the errors which may 
result from experiment. He has been told that inoculation affords 
a test by which we may decide in medico-legal inquiries now, as 
it is well established that there are true chancres which are not 
inoculable, it therefore cannot possess a positive value. What 
would be thought of a test without a positive value, and of which 
the negative response is to be totally disregarded ! 

Certain ulcerations are observed in the buccal cavity, which may 
be regarded as syphilitic ulcerations, and here I include those which 
are primary and secondary, as in a practical point of view, the 
difference is of no great importance. Mercurial may resemble 
venereal ulcerations. When mercury affects the mouth it produces 
ulcerations, the base of which is whitish, milky, and not gray or 
yellow, like the syphilitic ulceration ; in fact, they rarely exhibit 
ruptured vessels. The circumference of mercurial ulcerations, 
instead of being like the syphilitic, of a violet red color, is pale, 
like the interior of the mouth. These mercurial ulcerations are 
found particularly within the cheeks, on the edges of the tongue, 
and especially behind the molar teeth ; they are numerous, and 
their edges are neither indurated nor perpendicular. Syphilitic 
ulcerations may occur in the same situation, but they are most fre- 
quently observed on the palate, the tongue, tonsils, pharynx, and 
at the commissures of the lips ; their edges are perpendicular ; they 
are indurated and few in number, being sometimes three or more. 
Besides, in the mercurial ulceration there is a peculiar odor, with 
more or less salivation, and the patient complains of a metallic 
taste. 

Complications. — In speaking of the varieties of chancre I have 
asserted that in reality they depend on complications. There are 
two other complications or accidents, of sufficient importance to be 
separately described ; these are phimosis and paraphimosis. As 
buboes may occur without a previous chancre, and as accidents 
completely primary, I shall treat of them under a separate head. 

This is an appropriate place for noticing a case which I believe 
to be unique." It is that of a chancre of the meatus urinarius, 
which so narrowed this orifice as to produce a retention of urine ; 
a perforation of the bladder afterwards occurred which might have 
been regarded as a chancre, or a rupture arising from certain 
alterations which rendered it easily broken. The following are 
the particulars, as they were carefully noted by my interne, M. 
Codet. In connection with the report is a sketch of the pathologi- 
cal specimen. 

C. (L), a water porter, set. 26, temperament nervo-sanguineous, 
constitution robust. Admitted March 18th, 1852, Ward No. 10, 
bed No. 12, under the care of M. Yidal. Health always good. 
He ate heartily and drank much wine. Three years since he had 
a chancre in the burrow of the glans near the frsemim. After light 
treatment it healed in the course of three or four months. No 

14 



210 VIDAL ON VENEREAL DISEASES. 

enlarged ganglia in the groin or in the neck. The cicatrix of the 
chancre is smooth and soft as the parts by which it is surrounded. 
No consecutive accidents. Eighteen months ago he contracted 
a blennorrhagia ; during this attack there was no retention of urine. 
Pain was moderate during micturition, and the latter was followed 
by slight hemorrhage. Slight pain in perineum. Orchitis on the 
right side soon followed; this was cured in fifteen days. The 
blennorrhagia lasted for three months. 

In the early part of February 1852, he had another attack of 
blennorrhagia, which appeared fifteen days after a suspicious inter- 
course. The discharge was very small, and there was but little 
pain in urinating. C. does not know whether at this time there 
were enlarged ganglia. A potion and injections were prescribed, 
but this treatment was very imperfectly followed, and at the end 
of five or six days it was abandoned, the patient resuming his usual 
habits of life, drinking to excess, and perhaps working more than 
ordinarily. He wore no suspensory bandage ; the discharge was 
slight, as were his sufferings. This state of things lasted until the 
14th March, 1852. 

About the 13th of March, the patient experienced some diffi- 
culty in urinating ; but on the 14th he was seized with an intense 
cephalagia, and violent pains in the flank. The urine was voided 
with difficulty, and its emission was accompanied with a trifling 
hemorrhage. Constant tenesmus, anorexia, bitter taste in the 
mouth, severe thirst. On the 15th, the desires to urinate were 
very urgent. Micturition more and more difficult ; slight pains in 
the epigastric region ; spittle tinged with bile. This condition be- 
came aggravated, and the patient entered the hospital on the 18th 
March, 1852. 

18th. — Difficulty in walking. He arrived in a carriage, and it 
was necessary to support him, whilst he mounted into the ward ; 
every movement, he stated, increased his suffering, which was in 
the sides. For three days he has passed but a few drops of urine. 
The complexion is a little discolored, and there is an expression 
of suffering on the countenance. The pain in the head and sides 
is very intense. Abdomen slightly distended; there is dulness 
for nearly an inch below the umbilicus, whilst above, there is 
tympanitic resonance. The pulse is feeble and frequent, the 
tongue slightly loaded, the mouth bitter, thirst severe. From 
time to time, the patient discharged some mouthfuls of bile. Ees- 
piration is a little accelerated. 

The prepuce, red and swollen, permits the meatus to be with 
difficulty exposed. On the part adjacent to the frenum, a chancre 
was found, of the existence of which the patient was unconscious, 
and whose base was a little indurated. The surface of the ulcera- 
tion is limited, it extending about a line into the canal. A little 
muco-purulent matter lies between the lips of the meatus •; pres- 
sure on the urethra does not increase the quantity. An examina- 
tion, per rectum, detected a slight enlargement of the prostate. The 
ganglia in the groins are slightly enlarged (for what length of time 
patient does not know). The glans, like the prepuce, is red. The 



CHANCRE. 211 

meatus, very contracted, will not admit an ordinary silver cathe- 
ter ; a small, gum elastic instrument, a little larger than a raven's 
quill, introduced within a stylet, passes with facility. The pain 
is somewhat severe. Half a pint of urine was evacuated. Its flow 
was arrested (the eyes of the catheter having become obstructed). 
A second catheter of the same kind, introduced in the same man- 
ner, encountered some difficulties at the meatus, after which it 
passed with ease ; it gave exit to nearly a pint of muddy, highly- 
colored urine, which exhaled a decided ammoniacal odor. The 
urine issued in a jet. 

In withdrawing the sound, it was closely embraced by the 
canal. After the use of the instrument, some drops of blood 
appeared at the meatus. Some hours afterwards, I attempted 
again to introduce the catheter ; it was arrested on a level with 
the bulb. A large cataplasm moistened with laudanum was ap- 
plied to the perineum (he had taken no bath at the hospital). In 
the evening the patient felt better ; he passed his urine without 
the catheter. Abdomen still swollen, general condition same as 
in the morning. Laudanized cataplasms to the perineum, and to 
the abdomen. On the 19th, M. Yidal saw the patient. Condition 
same as yesterday. Examination by the rectum detected a slight 
enlargement of the lateral lobes of the prostate, which were sepa- 
rated by a slight furrow. This enlargement was not painful on 
pressure. No pain in the perineum. M . Yidal enlarged the 
meatus with a bistoury. A silver catheter then passed to the 
bladder without difficulty ; nearly a pint of urine was evacuated. 
Cataplasms with laudanum ; two pots of whey ; twenty leeches to 
the perineum. In the evening, the catheter was readily passed. 
Eespiration more difficult than in the morning ; fatigue increased. 
The urine deposited a sediment, having the aspect of blackish 
powder. 

20th. — Passed a restless night ; thirst troublesome ; countenance 
somewhat changed from yesterday ; abdomen more distended. 
The severity of the other symptoms has not increased. Bath ; 
laudanized cataplasm. In the evening, the lips of the wound 
assumed the aspect of a chancre. Patient is much worse ; eyes 
hollow ; cheek-bones prominent ; naso-labial prominence very 
marked ; pulse small, intermittent ; pulsations from 110 to 120 in 
the minute ; no chills ; abdomen moderately distended, but little 
painful. Patient is troubled with vomiting of bile. 

21st. — Bad night; delirium. Pulse very feeble, and intermit- 
tent, 130. Yomiting, almost constant, of pure bile; severe thirst ; 
dyspnoea increasing. Abdomen tympanitic. Constant agitation 
of the patient in bed. 

Catheter passed readily, and brought away a little urine. When 
it reached the bladder, it seemed to be closely embraced by the 
neck of this organ, and its movements were limited. Apply one 
oz. of Neapolitan ointment to the abdomen ; laudanized cataplasms. 
In the evening, the patient was a little better, and could urinate 
without the catheter. 

22d. — The slight improvement of yesterday has not continued. 



212 VIDAL ON" VENEREAL DISEASE& 

Violent delirium during the night ; anxious respiration ; counte- 
nance rapidly changing ; pulse thready and very frequent ; con- 
stant vomiting of bile. Lungs perfectly sonorous, except poste- 
riorly, along the pulmonary depression, where the sound is a little 
obscured, and mucous rales are heard. The abdominal walls, 
constantly distended, were a little painful on pressure. Pain in 
the sides very severe. Catheterism ; bath ; continuation of the 
mercurial ointment; tilleul, two pots (the whey yesterday pro- 
duced a slight diarrhoea) ; laudanized cataplasms. In the evening 
pulse was almost imperceptible. Countenance of a yellow com- 
plexion ; features very sharp ; lips dry ; tongue coated ; sides 
constantly painful on pressure ; slight delirium ; extremities cold. 
The catheter evacuated some spoonfuls of urine. 

23d. — Patient was delirious the whole night. Constant picking 
of the bed-clothes. A small quantity of urine was passed by the 
instrument. Forty leeches to the abdomen ; bath ; laudanized 
cataplasms. Noon. — Abdomen less swollen; eyes convulsed; 
lips of a violet color; extremities cold. No pulsation at the 
wrist. Died at four o'clock in the afternoon. 

Autopsy, forty hours after death. Weather cold and dry. The 
body exhibited no signs of putrefaction. Cadaveric rigidity very 
decided. The abdominal walls, having been opened by a horizon- 
tal incision below the umbilicus, were found infiltrated with a red- 
dish brown liquid, and were evidently softened. Adhesions, con- 
sisting of false gelatinous membranes, existed throughout the con- 
volutions of the intestines. The bladder adhered likewise to the 
parietes of the abdomen ; it had mounted about an inch above the 
pubes. Its external surface was of a deep violet color. In order 
to expose the parts most involved, the urethra was divided through- 
out its entire length by its superior wall ; the symphisis pubis 
was also divided. An incision was made through the prostate 
from its pubic surface, and the bladder was opened by its anterior 
wall. It contained but little urine. Its internal surface was gen- 
erally red, particularly about the trigonem. On the right side of 
the bladder was found an ulceration about the diameter of a twenty 
centime piece ; this ulceration penetrated through the whole thick- 
ness of the organ ; beneath it were false membranes themselves 
perforated, at two or three points, by which the bladder commu- 
nicated with the abdomen. (As before stated the original sketch 
has been reduced to one-fifth its size.) 

The edges of this ulcer were clearly formed, and round, resem- 
bling a cap surrounded by a well-developed vascular band ; on 
this cap were seen small irregular whitish layers, which seemed to 
be sub-mucous and a little hard, like incipient vegetations ; they 
were scattered over the whole internal surface of the bladder, 
but in much less number, than around the perforation. 

The prostate was but little enlarged ; the volume of each lobe 
being about that of a small nut. Its substance was highly in- 
jected. The urethra was perfectly sound. At the meatus, the 
chancre was found, to which we have alluded. Testicles sound. 
The soft parts in the lower pelvis were softened and somewhat in- 




w 



s: 



/?< • /c^'st /K^rtf *** 






Plate 3' 




A 






&&z*tau;4. 



Sinclair Lith 



CHANCRE. 213 

filtrated with, urine. In the abdomen were traces of a violent 
peritonis. Sero-pnrulent effusion, large quantities of false mem- 
brane, covering all the contents of the abdomen ; as well as be- 
tween the liver and the diaphragm. The kidneys presented no- 
thing unusual ; by pressure, however, a milky fluid was made to 
issue from some of the calices ; in other respects they were per- 
fectly sound. The stomach and intestines when examined from 
their internal surfaces were sound. The liver was congested. The 
spleen, very friable, was reduced almost to a pulp. The heart 
was sound. The lungs presented no traces of tubercles ; they 
were a little congested only, at their posterior surface ; a portion 
of their surface taken from this region would not float in water. 
The brain was slightly injected. The inguinal and cervical gan- 
glia were red and moderately swollen. 

There was, in this case, a solution of continuity in the bladder, 
which permitted the urine to be effused into the cavity of the ab- 
domen, an accident which was mortal. The retention of urine 
could have resulted only from the enlargement of the prostate, 
which, however, was not considerable^ An obstacle existed at 
the meatus, where was seated an indurated chancre ; but this ob- 
stacle was trifling, for a gum-elastic catheter, of small size indeed, 
(a little larger than a raven's quill,) could be introduced into the 
bladder. Thus, the obstacle was not sufficient to cause of itself a 
rupture of the bladder. The perforation, moreover, did not pres- 
ent the characters of a lesion entirely physical. 

1st. Did the instrument (the catheter) perforate the bladder? 
Besides that it wanted the characters of an entirely physical lesion, 
it may be added, that the catheter was at first introduced by a 
well-informed pupil ; it was small, of gum elastic, and as the stylet 
was not used, consequently it must have been very flexible. After 
the division of the meatus, I myself introduced the silver catheter, 
and always with the greatest care.. I found no resistance, and its 
introduction therefore required no effort. In no instance was the 
catheter allowed to remain. Thus, the rupture or perforation of 
the bladder, does not appear to me the very probable result of a 
physical lesion. There remain two other hypotheses. 

2d. As there was a chancre at the meatus, a very inoculable 
one, we may suppose that the first small catheter became charged 
in its eyes with a certain quantity of virulent pus, and which being 
thus carried into the bladder produced a chancre, or perforation by 
ulceration in this organ. To this may be objected the short time 
which elapsed between this inoculation and the phenomena that 
announced the approaching death of the patient. But may not 
the progress of chancre in the bladder be much more rapid than 
that of other parts ? The place to which I have assigned this 
case, shows that I incline towards the opinion that it was a vesical 
chancre. This, however, is only an hypothesis, and I think it 
would be difficult even after having examined the preparation, to 
decide positively on its nature. 

3d. Now, for tlje third hypothesis. Small firm elevations like 
vegetations were observed in this case. They are well represented 



214 VIDAL ON VENEREAL DISEASES. 

in the annexed plate ; thej are seen at several points of the blad- 
der, at the bas-fond, and around the perforation. It is evident 
that, had these growths been somewhat analogous to arterial con- 
cretions, the bladder could not have retained its normal consist- 
ence ; it could not have been dilated here as at other points. Now, 
it may be supposed that the urine, meeting with an obstacle to its 
passage, has distended the bladder in the same manner as when 
it was sound, but which now diseased, yielded at its most fragile 
part, viz., the seat of these morbid growths. According to this 
hypothesis the chancre at the meatus must play an important part, 
though a physical one ; it obstructed the passage of the urine. 
But whence these morbid growths in the bladder? The sub- 
ject having had several attacks of blennorrhagia, having also 
had a chancre at the meatus for a longer period than that which 
he mentioned, these productions may be regarded as venereal 
warts. 

Prognosis. — This should be regarded both in reference to the 
local symptoms and the constitutional disease. Considered in the 
latter point of view, all chancres are equally grave, since, in their 
early stages, all resemble each other : the varieties do not become 
established until the absorption of the virus has already taken 
place. The effects of this poison on the system, the formation of 
a diathesis, do not therefore at all depend upon the character of 
the chancre, but the state of the system, its susceptibility to its 
action, and the manner in which it reacts. Here, hygienic condi- 
tions, idiosyncrasy, a well-directed treatment, exert a great in- 
fluence in the establishment of the diathesis and the constitutional 
disease. I will not repeat what I have said as to the connection 
existing between the indurated chancre and the syphilitic diathe- 
sis, and the pox. The indurated chancre does not produce the pox: it 
proves only that general infection has already taken place. In the 
second point of view, it is evident that the phagedenic chancres 
are the most grave ; the gangrenous, diphtheritic and serpiginous 
forms may give rise to very serious effects. For example, we find 
the gangrenous chancre destroying the penis, whilst the serpigin- 
ous^may dissect the region of the nates. The effects, then, are not 
confined to the part or parts invaded by this terrible ulceration, 
for the constitution becomes exhausted by the pain, the abundance, 
and duration of the suppuration, which are the common effects of 
the serpiginous phagedenic chancre. 

Treatment — 1st. Abortive Method. — To destroy the chancre with 
caustic, the knife — in fine, to substitute for it a simple wound, 
capable of speedy cicatrization, and thus preventing general infec- 
tion, was Hunter's idea, which some have tried to realize in France. 
But for this purpose, three things are requisite: — 1st, that the 
virus shall not have had time to enter the system ; 2d, that in the 
case of localization, we should know the limits of the affected 
locality ; 3d, as those who maintain that chancre is local, admit 
that it is so only for a limited time, it is necessary to fix the limits 
of this time. Now, these facts have not been furnished by those 
who believe that chancre is a local affection, whilst the contiary 



CHANCRE. 215 

has been proved by well-authenticated cases. Indeed, chancres 
have been destroyed by the canstic, or knife, but general infection 
has not been prevented ; sometimes, even in these cases, the chancre 
has returned and the pox has followed. The reader should here 
consult the paragraph, entitled, Incubation, not the localization of 
chancre. I there spoke of a physician who saw the very first ap- 
pearance of the chancres on his own person, who cauterized them, 
and in whom they cicatrized, and yet the pox was not prevented. 
Facts of this kind are not rare, and analogy corroborates this view 
of the subject. We know that the first effect of the syphilitic 
virus has often been compared to the bite of a viper or the sting 
of a venomous animal. M. Eicord often compares chancre, on its 
first appearance, to the bite of a viper. I believe that this is a 
very just comparison, of which we may be satisfied by the perusal 
of the following case, which may be found in almost every medi- 
cal journal. The case is most authentic, proving the simultaneous 
production of the local and general effect, and that cauterization 
was completely impotent to destroy the effects of the poison. M. 
Dumeril would certainly have died, if the bite of a viper was 
always mortal. 

" M. C. Dumeril was walking, on the 12th of this month, in the 
forest of Senars. Having discovered a viper which, from its size, 
appeared to belong to a new species in our climate, the learned 
professor seized it with his hand, expecting, by breaking its dorsal 
spine, to kill it ; but, either because the animal was too strong, or 
that he was not properly seized, he bit his adversary deeply. Five 
successive bites on the hand and arm did not induce this votary of 
science to relax his hold, and the suffocated viper became his prize. 
M. Dumeril fortunately was accompanied by his son, a physician. 
The latter instantly sucked the wounds, and cauterized them with 
caustic potash. Notwithstanding these precautions, and imme- 
diate attention, the poison produced its effects. M. Dumeril, after 
two protracted fainting fits, was seized with vomiting. In this 
condition he was carried home, where he remained for twenty-four 
hours under the influence of the poison. At the end of this time 
the alarming symptoms disappeared, and the learned professor re- 
sumed his course at the Jar din des Plantes. 11 '* 

Thus, in spite of every precaution and attention, the poison en- 
tered at once into the system, and produced its constitutional 
effects. The reader may refer to what I have stated about the ex- 
periments of M. Kenaud, to prove the rapid action of the virus of 
glanders, and what M. Bousquet has established respecting the 
vaccine virus. JSTow, the same observations apply to the venereal 
poison. 

But, let us examine the so-called abortive method, and the other 
plans of local treatment. I will afterwards mention that which I 
deem the most efficacious in promoting the cicatrization of chancre, 
and in preventing general infection. M. Katier, an advocate of 
cauterization, and believing in the existence of the pustule as the 

* Gazette Medicate, Sept. 20th, 1851. 



216 VIDAL ON VENEREAL DISEASES. 

earliest symptom of chancre, calls his method of treatment the 
ectrotic method. According to M. Eatier, the pustule is about the 
size of a grain of millet-seed ; it is filled with serum, more or less 
transparent ; it remains for a short time a perfect pustule ; it ap- 
pears from about the third to the eighth day. M. Eatier advises 
the excision of its summit, with flat curved scissors, the complete 
evacuation of the fluid which it contains, and washing it with 
water in which has been dissolved a sixth part of the chloride of 
soda. The result of these proceedings, under the circumstances, 
is certain : it is less so when the pustule is left to break, in which 
case some of the debris remains. 

I would remark, that it appears to me very difficult to find a 
pustule of the size of a grain of millet-seed, the summit of which 
may be excised with flat-curved scissors. And then the debris 1 
( Vid. Eatier, Meihode ectrotique, Archives de Medicine.) 

M. Eicord once was satisfied with cauterization made by a 
crayon of nitrate of silver. He now resorts to monohydrated 
nitric acid, and to the Yienna paste, according to the following 
formula : 

ty. Quick Lime, 5 parts. 
Caustic Potash, 6 parts. 

Mix and dilute ivith sufficient alcohol to make a paste. 

One word in passing, in reference to the necessity of abandon- 
ing the nitrate of silver for caustics, of the power of those just 
mentioned, this implies some failure of success by the former 
method, and a deep penetration of the virus during the earliest 
stages of chancre, that is to say, at a time when the abortive 
method is regarded possible and rational. [The yqtj first case in 
the Treatise of M. Eicord, shows that cauterization, even before, 
or at the fifth day, does not always prove effectual. In speaking 
of the localization of chancre we proved even by M. Eicord him- 
self, that cauterization must often fail, as the limits of the sphere 
of infection in chancre cannot be ascertained. Mr. Lane is dis- 
posed to rely on the abortive treatment for a much longer rjeriod 
than M. Eicord, and observes, that he should be much surprised 
to find any sore which healed within a fortnight of the application 
of the original poison, followed by secondary symptoms (Lect. in 
Lond. Lancet, July 30, 1842, p. 597). Now in page 594, he incul- 
cates in strong terms, that an ulcer with or without induration, may 
be followed by constitutional disease. The secondary accidents 
he attributes to the continued absorption of the matter reproduced 
by the primary sore, " the enormous quantity thus generated and 
retained in contact with the living tissue may be judged of, when 
I tell you that hundreds or even thousands of persons might be 
inoculated daily from a single ulcer." (p. 498). On the same page, 
Mr. Lane admits that the poison of syphilis, when applied to the 
living tissue in a fluid state, is instantly absorbed into the circu- 
lation, but in the ordinary mode of application, the quantity is too 
small to produce any appreciable effect. Now, one of the most 



CHANCRE. 



217 



perfect examples of complete constitutional infection which has 
ever come under our notice, followed a very small primary sore, 
which was thoroughly cauterized on its first appearance, and, 
in addition to this the patient, a very healthy robust man, 
was immediately salivated. "With the greatest deference to so 
high an authority, we feel confident that numerous facts might be 
quoted to show that even M. Eicord in assigning the fifth or sixth 
day as the period on which we may rely on escharotics, in the 
abortive treatment of syphilis, has gone farther than experience, 
even his own, can warrant. The action of morbid poisons has 
been most ably discussed in the Lecture, to which we have re- 
ferred, and which we strongly recommend to the reader's attention. 
Mr. Lane's practical belief may be inferred from the following extract 
of a letter with which this gentleman has kindly favored us, dated 
June, 1853 : "I give mercury so as slightly to affect the mouth, 
not only in indurated chancre, but in all primary sores, unless 
some more than ordinary reason forbids. I give it not so much 
in order to heal the sores (except when indurated) as a preventive 
of the constitutional contamination (the italics are our own). I prefer 
escharotics, however, when patients will submit as the surest 
means of protecting the constitution. I use pure nitric acid for 
this purpose. This acid we believe to be the surest escharotic 
which we possess. — Gr. C. B.] 

An opinion may be formed of excision by the results of circum- 
cision during the existence of chancres on the edge of the prepuce. 
The results of this operation are very various. I have sometimes 
cut beneath chancres which appeared to be not completely cica- 
trized, and the wound by means of sutures healed by the first in- 
tention. At other times I have excised nearly four lines beyond 
a chancre perfectly cicatrized, the wound was made in parts ap- 
parently completely sound, and yet two days afterwards this 
wound has been transformed into a large phagedenic chancre. I 
have made incisions into indurated prepuces which resembled a 
shell covering the glans, and yet the wound has speedily cicatrized ; 
at other times, and in analogous circumstances, it has assumed a 
bad aspect, an obstinate serpiginous character. This method, 
therefore, has several inconveniences. The principal, is, that the 
edges of the wound are likely to put on the specific character of 
the chancre, which renders excision as irrational as cauterization, 
for they are based on a false idea of the connection between chancre 
and the organism, since they suppose the localization of the former. 
The abortive method, therefore, does not prevent general in- 
fection, nor has it the efficacy attributed to it. But is •it attended 
with the risk asserted by those who regard it is a wolf among the 
sheep ? In destroying and healing a chancre, do we thus prevent 
the elimination from the system of the virus, which is therefore 
left to produce its deleterious- effects on the system ? I believe 
that this opinion has been carried too far. I believe that infection 
has taken place even whilst the chancre is forming ; the local and 
general action are simultaneous. The danger lies not here. When 
cauterization succeeds in destroying and cicatrizing the ulcer, the 



218 VTDAL 02J VENEREAL DISEASES. 

patient, and sometimes the inexperienced practitioner, repose in 
false security, and do not resort to general or specific treatment to 
prevent the development of constitutional disease ; hence, under 
such circumstances, it is more likely to appear and to be severe. 
Besides the other risks which M. Chomel attributes to cauteriza- 
tion, he insists upon that to which we have just alluded. Depuy- 
tren was an avowed enemy of cauterization ; he called it the most 
fatal of methods* 

It is therefore useless to search for the best methods of destroy- 
ing chancres, we must learn how to treat them. 

2. Dressing. — Even here M. Eicord would cauterize. If the 
chancre be not thus destroyed, we may always diminish its ex- 
tent, reduce the surface of absorption, and consequently the chan- 
crs of infection. (This, by the way, is a condemnation of the 
practice of those surgeons who inoculate with the matter from one 
patient to another ; for in multiplying the chancres, that is, 
the surfaces of absorption, they increase the chances of general in- 
fection.) He also advises, that we cauterize with the nitrate of 
silver or nitric acid as often as the ulceration reappears after the 
separation of the eschar; when it assumes the characters of a 
wound, and cicatrization has taken place, we should cease to cau- 
terize. There is here a difficulty, viz. to distinguish a real ulcer- 
ation from a wound, in other words, from the ulceration in process 
of cicatrization. 

As to dressings, properly so called, M. Eicord generally abstains 
from the use of ointments, especially the .mercurial. He fre- 
quently makes use of the aromatic wine, according to the formu- 
lary in the codex. M. Baumes adopts the following formula : 

^ . Sugar Candy, 3 i. 
Wine, I i, 

The following is M. Eicord's practice : 

The ulcer is washed with wine, without however irritating it, or 
causing it to bleed ; it is then covered by a bit of fine charpie 
dipped in the same wine, sufficiently moist to remain so without 
being colored ; if saturated with too large a quantity, the kind of 
maceration which results is productive of bad effects. At each 
dressing, to loosen the charpie, it should be soaked with wine, so 
as not to lacerate the parts to which it may adhere when dry. 
According to M. Eicord, as the result of this mode of treatment, 
successive chancres never appear, as so frequently occurs after the 
other methods. The aromatic wine diminishes the purulent se- 
cretion, tends to promote cicatrization by modifying the surface 
of the virulent ulcer, and in acting as an astringent on the adjacent 
parts, it renders their inoculation impossible. When the dis- 
charge continues to be copious, we must have recourse to the 
vinous decoction of tan bark. M. Eicord now prefers the fol- 
lowing solution : 

* Legons Orales, t. I, p. 108. 



CHANCRE. 219 

^ . Tart, Fer. et Potas. 3 iiss. 
Aq. Oct. iss. 

If the ulcer be painful, the aromatic wine often augments the 
suffering ; by adding from one to one and a half ounces of the 
gummy extract of opium to an ounce of the above solution, it be- 
comes a useful topical application. Among those who continue to 
suffer, there are some in whom the pains are removed by increasing 
the quantity of opium, whilst in others they are only diminished. 

There are cases in which we are compelled at once to suspend 
temporarily the medicated wine or the ferruginous solution, and 
even to renounce it completely. Thus, in certain patients, sup- 
puration ceases, and the ulcer remains stationary ; a dressing must 
then be used for some days of emollient decoctions or of opiated 
cerates. The wine and the ferruginous solution may afterwards 
be resumed. In others, the ulcer being indurated, these dressings 
increase the induration, and prevent cicatrization. Aside from 
these circumstances, according to M. Eicord, so easy to be dis- 
covered and regarded, the means already indicated should con- 
stitute the general method of dressing. Once the period of cica- 
trization arrives, and progresses with regularity, we continue the 
dressings. M. Eicord does not cauterize, unless it be necessary to 
repress the exuberant granulations. Finally, it often happens 
that only the epidermis is wanting to complete the cure ; the sur- 
face of the ulcer attains the level of the surrounding parts, re- 
mains red, is seldom covered with matter, and yet the ulcer does 
not heal. Then the gentle application of the nitrate of silver, so 
as to whiten the surface without cauterizing it, to any depth, suffi- 
ces to finish the cure. According to M. Eeynaud, powerful caus- 
tics, especially the nitrate of silver, increase the risks of adenitis. 
This naval surgeon prefers the mercurial solutions. He takes 
from ten to fifteen grains of the bichloride of mercury to the 
ounce of distilled water. The chancre is touched with little folds 
of charpie, saturated with this lotion, and this practice is followed 
for four or five days. It must be discontinued if the ulcer assume 
a vermillion color. If the aspect be doubtful, the applications 
are to be continued. In all cases we must void excessive irrita- 
tion of the tumor. 

M. Eicord, in cases of the regular chancre, confines himself to 
local treatment, where it leaves no induration behind. I have under- 
lined the above passage, as it leaves us to infer that the regular 
chancre may be indurated. For my own part, I always admit the 
existence of more or less induration. As it will be seen here- 
after, I never confine myself to local treatment. M. Eicord never 
loses sight of induration during his treatment. Indeed, by ex- 
tending, it may oppose cicatrization, and by the strangulation re- 
sulting from the indurated tissues, it may produce gangrene, and 
frequently phagedenic disease. In ordinary cases, which are the 
most simple, the indurated chancre is dressed with : 

5 . Calomel (d la vopeur) gr. xv. 

Pomatum of cucumber or Opiated Cerate 3 i. 



220 YIDAL ON VENEREAL DISEASES. 

Charpie smeared with this ointment is applied, and it mast be 
renewed three or four times in the day. 

[Mr. Langston Parker, referring to the general applicability of 
the treatment by the mercurial vapor bath, remarks, that there 
are some forms of disease which yield with greater rapidity than 
others. " That which gives way with the greatest difficulty is the 
induration which succeeds to the healing of a primary sore. I do 
not mean that soft fulness which is sometimes found in such situa- 
tions, but that cartilaginous hardness which is met with under the 
skin, and which is sure, sooner or later, to end in local or consti- 
tutional mischief. I have seen cases which have resisted all modes 
of treatment but the baths ; to these they yield but slowly, but 
they do yield, and with certainty, after other plans of treatment 
have been followed for months without success, or with but par 
tial amendment" (On the Treatment of Secondary Syphilis, by a Safe 
and Successful Method, &c. p. 16). It has been proposed to destroy 
this persistent induration, with caustic or the knife ; but as is ob- 
served by Mr. Egan, " An intractable species of ulcer usually re- 
sults upon the application of the caustic, and excision but removes 
the original sore, to be replaced by one of a less manageable de- 
scription, which, upon healing, will ; in all probability, exhibit the 
same characteristic induration of its predecessor" (ftp. cit. p. 228). 

Mr. Key was decidedly opposed to the use of mercurial appli- 
cations, their action, in his opinion, being to increase the ulcera- 
tion and the secretion. " Mercurial washes or ointments, in the 
ulcerated stage, I employ, not as a general rule, but as the excep- 
tion in sores indolent, not sensitive, and secreting but sparingly. 
In the larger number of sores, mercurial applications are hardly 
admissible in our list of remedies : the common astringent salts — 
as the preparations of silver, lead, zinc, and copper — varied as the 
state of the sore will' bear, check the disposition to spread quickly, 
and bring on an appearance of granulations. To the premature 
use of mercurial dressings much of the troublesome career of their 
sores may be attributed," &c. {Report of Primary Syphilitic Cases. 
Guy's Hosp. Reports, vol. iv.). Mr. Key advises, that, in the ul- 
cerated stage, rf mercury is administered internally, it should be 
given sparingly and cautiously watched, and with it he would com- 
bine the use of local astringents. The method recommended by 
Mr. Parker is certainly that which seems liable to the fewest ob- 
jections. — Gr. C. B.] 

In the case of copious suppuration, the chancre is first to be 
washed with the aromatic wine, which may be employed alone if 
the discharge be too copious. Should the patient be irritable, and 
an inflammatory complication exist, and especially when the gan- 
grene above mentioned is spreading, opium should be used both 
internally and externally. In such cases I administer both morn- 
ing and evening, camphorated pills of opium, the formula for 
which I have already given when describing the means for sub- 
duing erections which occur in blennorrhagia. The concentrated 
solution of opium answers best as a dressing. Antiphlogistics, 
however, must not be omitted. Thus, when the patient is young 



CHANCRE. 221 

and robust, I often resort to venesection. I recommend bathing 
and the application of laudanized cataplasms, if the locality 
permit. 

3. Author's Method. — I attach but secondary importance to the 
use of local means. I do not generally resort to cauterization un- 
til after cicatrization has commenced, and the chancre has passed 
into the condition of a wound. Then, if this wound granulates, I 
check the exuberant growths with the nitrate of silver, applied 
rather strongly ; if the traumatic surface present a languid aspect, 
I stimulate it by gentle applications of the same caustic, which 
then skines over the solution of continuity. With regard to dress- 
ings properly so called, I sometimes use a mixture of aromatic 
wine and one third of water. I believe that it is often better to 
substitute for astringent and irritating injections those of an emol- 
lient character. I have seen dressings of too irritating a nature, ex- 
cite inflammatory complications. It will here be recollected, that 
the followers of Broussais attached great importance to the use of 
antiphlogistics, and that their treatment was often followed by 
success. (Of course I speak of the cure of chancre only, and not 
of the pox.) I rely especially on general treatment, and the fol- 
lowing is that in which I have the most confidence : 

1st. General bathing ; two days of perfect rest. 

2d. If the patient be young and robust, bleeding from the arm. 

3d. The next day, a saline purgative ; Seidlitz water or citrate 
of magnesia. If the patient be feeble, of the lymphatic tempera- 
ment, I commence with a cathartic. 

4th. Pills of the bi-chloride of mercury, according to the follow- 
ing formula, which is nearly the same as that of Dupuytren : 

3. Hydrarg. Bi-chlor. 
Ext. Thebaiq. aa gr. I 
Cons. Kos. q. s. 
Ft. pil. 25. Take one morning and evening. Jj(* 

This treatment, adopted in the early stages of chancre, and con- 
tinued for two months, promotes cicatrization, prevents the devel- 
opment of secondary accidents, or if it fail to prevent, they are 
singularly mitigated. But it is very necessary that it be continued 
for the time prescribed without interruption. If from carelessness 
on the part of the patient, or intolerance of his system, the admin- 
istration of the pills is interrupted for only eight days, no depend- 
ence can be placed on what has been given ; the treatment must 
then be commenced anew, and with much less chance of success. 
But the preliminary measures, such as blood-letting and purga- 
tives, dispose the system favorably to the tolerance of the mercury. 
In females, who, by their more lymphatic temperament, cannot 
bear repetitions of the loss of blood, we frequently observe acci- 
dents which compel us to suspend the use of the pills. 

This method has rarely failed, in other words, it has been pro- 
phylactic against general infection in every instance in which it 
has been resorted to in time, where it has been well managed and 



222 VIDAL ON VENEREAL DISEASES. 

regularly followed. This lias been the basis of my practice for 
fifteen years. It has been asserted that patients thus treated have 
had consecutive accidents. If these patients had been carefully 
interrogated, it would have been found that some one of the cir- 
cumstances above mentioned had interrupted the constant use of 
the mercurial pills, or, indeed, that the treatment had been under- 
taken at a time when the chancre had already acquired a degree 
of induration which indicated the existence of the syphilitic dia- 
thesis. Then, the mercurial treatment was insufficient; other 
means must be employed, which I will mention when I consider 
the treatment of confirmed syphilis or that of the indurated chan- 
cre, which itself is an expression of the syphilitic diathesis. 

[If it be true, as stated by M. Eicord in his Letters (No. XXX.) 
that the persistence of the syphilitic diathesis is not incompatible 
with good health, and that this diathesis may last for ten, fifteen, 
or thirty years, it is difficult to estimate the prophylactic value of 
mercury, or any other agent. Even though we administer, as 
advised by him, a daily dose for six months, we cannot be sure 
that we have prevented the future development of the presence 
of this diathesis. We need not, therefore, be surprised at Hun- 
ter's contradictory statements upon this subject. When mercury 
is employed in the treatment of chancre, we find that in a given 
number of cases no secondary accidents appear ; again, if mer- 
cury be dispensed with altogether, we find that a large number 
escape, or at least never show any manifestation of constitutional 
infection. In the treatment of the true Hunterian chancre, nearly 
all civil practitioners are agreed as to the necessity of resorting to 
this remedy. Military surgeons, however, boast of extraordinary 
success, from simple treatment alone. In the Clinical Lectures of 
Mr. Carmichael, or in the Lectures of Dr. Graves (2d Dub. ed., p. 
385), the reader may find reports highly favorable to the non- 
mercurial practice. Mr. Guthrie treated some 100 cases on this 
plan, and though he arrived at the conclusion, that " every kind 
of ulcer on the genitals is curable without mercury," yet he be- 
lieves that in some cases a gentle course will expedite the cure. 
(Med. Ohir. Trans, vol. ix.) He does not, however, regard mer- 
cury as a specific in this disease. Sir George Ballingal has fur- 
nished quite a body of evidence in favor of the simple treatment, 
for which see the 4th edition of his Military /Surgery, p. 465. If 
cauterization is likely to succeed in any cases, it is in those which 
come under the care of army surgeons, for the soldiers are under 
orders to apply to the surgeons on the very first appearance of the 
disease. This is doubtless the cause of the superior efficacy of the 
simple treatment in military practice. Indeed, we have the testi- 
mony of Sir Benjamin Brodie, that Mr. Eose, who was so success- 
ful with the non-mercurial treatment in the army, in private 
practice was compelled, like other surgeons, to resort to this reme- 
dy. (Lecture in London Lancet, Feb. 1844, p. 673.) Sir Benjamin 
is a decided advocate for the use of mercury, not only as a pro- 
phylactic but a curative agent; and in this view of the subject, 
Messrs. Lawrence, Porter, Cusack, Lane, and Wilson coincide. 



CHANCRE. 223 

Mr. Langston Parker regards the simple, or " rational" treatment, 
except in the indurated chancre, with decided approbation '; and 
Mr. Egan, in alluding to the use of mercury, evidently considers 
that its employment should be restricted to this form of ulcer. 
The following different estimates of the liability to secondary 
accidents, when mercury is not used, are deserving of notice : 

NON-MERCURIAL TREATMENT. 



According 


to M. Cazenave, 


18 in 20 cases. 


« 


M. Repiquet, 


12 " 20 


« 


u 


M. Cullerier, 


10 " 20 


< 


<( 


M. Baunies, 


6 " 20 


« 


a 


M. Puche, 


4 " 20 


i 


« 


M. Ratier, 


" 20 


(C 


u 


Sir J. McGregor, - 


96 " 1940 


u 


« 


Dr. Pitcairn, 


" 768 


' 


u 


Mr. Spence, 


21 " 367 


« 


u 


Mr. Bacot, 


1 " 10 


( 



According to Sir G. Ballingall, the army reports show that, 
without mercury, one in twenty have secondary symptoms ; with 
mercury, one in fifty -five cases. The evidence, on the whole, goes 
to prove the correctness of the assertion of Sir Benjamin Brodie, 
that mercury surpasses all other remedies "in extinguishing vene- 
real disease;" yet there can be no question that, even when pro- 
perly and judiciously used, it, like all other agents, often fails to 
accomplish this object. A specific for syphilis is yet to be dis- 
covered. 

In conclusion, we can only add, that the principal British prac- 
titioners who are regarded as non-mercurialists, may be said to be 
Messrs. Ferguson, Eose, Guthrie, Hennen, Hill, Thomson, Alcock, 
Todd, and Dr. Graves ; whilst among our own countrymen, we 
may name Drs. Chapman, Dewes, Ware, Alexander H. Stevens 
(in secondary syphilis), Harris, Eousseau, and Phinney. — G. C. B.] 

The method of treatment which I here recommend has been 
sanctioned by the experience of very eminent practitioners. In- 
deed, Dupuytren, M. Chomel, Broussonnet, and others, have ac- 
knowledged the advantages of administering the bi-chloride of 
mercury in minute doses and for a length of time. M. Chomel 
strongly insists on the necessity of not interrupting the influence 
of the mercury. Dupuytren advised, after the chancre had healed, 
to continue the use of the pills which bear his name, as long, at 
least, as was required to produce the cicatrization of the chancre. 
M. Chomel, in his lectures, never fails to remark that it is not the 
quantity of mercury taken which best insures a cure, but the 
length of time during which the system has been modified by this 
agent. He recommends that the treatment should be continued for 
five or six months. M. Broussonnet gives Van Swieten's liquor in 
the dose of from one to two spoonfuls in the day till the patient has 
taken as many as eighty or one hundred doses. If the system is 
antipathic to this preparation he substitutes Dupuytrens pills, of 
which he gives from one hundred to one hundred and twenty. 

3. Treatment of the Phagedenic Chancre.^— -In the treatment of this 



224 YIDAL ON VENEREAL DISEASES. 

variety of chancre we should pay the greatest regard to the tem- 
perament of the patient, to the hygienic circumstances by which 
he is surrounded, and the treatment to which he has submitted, as 
well as to the complications which exist. The digestive organs, 
or the lungs, may be diseased ; sometimes there exists a dartrous, 
a scorbutic, or scrofulous diathesis. The latter especially most 
requires a specific treatment, and for a long time this complication 
has been regarded as most unfavorable : indeed, even Boerhaave 
remarked that if mercury does not always cure the pox it is owing 
to a strumous complication.* Mercury, instead of curing, aggra- 
vates a phagedenic ulcer. However, if it is prudent, in the ma- 
jority of cases, to abstain from mercurials in the treatment of the 
phagedenic sore, they should not be entirely banished, as in some 
cases they may have a real efficacy. If our efforts do not succeed 
we should not persist in their use ; it is better to resort to other 
means than to some new preparation of mercury. Generally the 
ferruginous and the preparations of iodine in small doses, the cod 
liver oil are preferable. Still we should not be exclusive in our 
treatment. 

[Mr. Langston Parker says that he has seen phagedena in the nose, 
throat, and on the penis, stopped at once by immersion in the baths 
for half or three-quarters of an hour. "No other remedy can be 
brought to bear thus speedily upon diseases of this nature, and the 
mutilations and losses of substance which occur in such states take 
place whilst we are waiting for the action of remedies." (On the 
Treatment of Secondary and Confirmed Syphilis, by a Safe and Suc- 
cessful Method, p. 28.) Surgeons are by no means unanimous in 
denouncing mercury in the treatment of phagedenic chancre. By 
"Wallace, Mayo, and Messrs. Lawrence, Porter, Skey, and Eicord, 
it is admitted that in some of these cases it is a very valuable 
remedy. Mr. Porter is very decided upon this subject. After 
alluding to the opposition to this treament by some of the highest 
authorities in surgery, he observes : " ISTow, with every deference to 
these authorities, and with a previous acknowledgment that cases 
will occasionally fall out forming exceptions to any general rule 
of practice, these are the very cases (as far as I can distinguish 
them) in which I am not only disposed to employ mercury, but to 
administer it in the form and manner most likely to bring the 
system under its influence." Mr. P. describes another form of 
phagedena produced by mercury, the medicine acting as a poison ; 
in such cases he would suspend it at once, and discard it altogether. 
(Led on Syph. p. 36. Dub. Med. Press, Jan. 20, 1847.) 

Mr. Key and Mr. Carmichael were among the opponents of mer- 
curial treatment in phagedena, and Mr. Acton (op. cit. p. 273,) says, 
" let the young surgeon never be induced to give mercury under any 
pretence whatever in acute cases of phagedena." The only excep- 
tion, he adds, is to be met with in a form of indurated chancre 
attended with central slough. M. Eicord acknowledges his ina- 

* Vid. Boerhaave, quoted by Astruc, lib. ii., p. 286, of the French translation. 
This is a very remarkable passage. 



CHANCRE. 225 

bility (Ed. of Hunter, p. 459,) to point out the cases of phagedena, 
in which mercury is likely to prove of service, though he states 
that there can be no doubt of its occasional efficacy in these cases. 
If we were to resort to it at all in phagedena, we certainly should 
prefer Mr. Parker's mercurial vapor bath to any other form of 
administration. — Gr. C. B.] 

When we have to treat a gangrenous chancre, the result of 
excessive inflammation, the first thing requiring our attention is 
the inflammatory complication. When I come to treat of phimosis 
and paraphimosis as complications of chancre, I will point out the 
course to be pursued. The phagedenic gangrenous chancre may, 
on the other hand, proceed from general debility ; this should be 
another reason for abstaining from the use of mercurial prepara- 
tions; here cordials, tonics, topical applications saturated with 
chlorine water will constitute the basis of our treatment. Accord- 
ing to M. Eicord, the local treatment of the pultaceous diphtheritic 
phagedenic chancres should resemble that of ordinary chancre. 
The combined use of cauterization and the dressings of aromatic 
wine, and especially the ferruginous solution. The cauterizations 
with the monohydrated nitric acid should be deep and repeated ; 
in some cases it should be practised twice a day to keep pace with 
the progress of the disease. The dressings should likewise be here 
repeated, for the discharge is very copious. There are ulcerations 
which are cured only after the employment of a kind of almost 
constant irrigation. During the use of the dressings we should 
guard against any lacerations, for each solution of continuity may 
become inoculated, and the removal of the skin favors the absorp- 
tion of virulent pus, which will still enlarge the boundaries of the 
ulcer. 

In the case of very severe local inflammation the application of 
leeches has been advised. In addition to the difficulty of making 
them bite at the points of ulceration the bites may cause an increase 
of the ulcer according to the depths of the tissues wounded. We 
must also guard against their application near a chancre, for each 
puncture made by them may be transformed into an ulcer. If the 
local inflammation compel the practitioner to resort to blood-letting, 
the leeches should be applied at a certain distance above the ulcera- 
tions. The bites should afterwards be covered with compresses 
soaked in emollient and narcotic decoctions, with cataplasms of 
starch or semolia and milk ; hot mucilaginous or gelatinous baths, 
and particularly a diet proportioned to the general or local con- 
dition, absolute rest, and diluent drinks, are here very beneficial. 
If there be much irritability or pain, with or without much inflam- 
mation, according as the one or the other predominates we must 
use the preparations of opium both generally and locally. 

M. Eicord uses the following solution for a dressing : 

I£. Aq. dist. lactucar. 5 viss. 
Ext. op. gum. 5 i. M. 

Even here this practitioner resorts to cauterization with the nitrate 

15 



226 VIDAL ON VENEREAL DISEASES. 

of silver, and regards it as a powerful auxiliary ; with hirn, pain 
or inflammation is no objection, as he considers that the nitrate of 
silver is one of the most powerful sedatives, and the most certain 
antiphlogistic when it is properly applied. The severe pain expe- 
rienced at the moment of cauterization soon subsides, and an 
improvement is manifested which we seek in vain from other 
medicines. This rule has but few exceptions. 

When the phagedenic chancre continues to progress or to remain 
stationary, we have seen good effects produced by carrot cataplasms, 
melted yellow wax, as a digestive ointment. In these cases, also, 
recourse has been had to the most powerful caustics, the butter of 
antimony, potash, alcohol, the arsenical paste of Eousselot or Frere 
Come, the actual cautery applied directly, or as an objectif cautery. 
The Vienna paste, and particularly the monohydrated nitric acid, 
have likewise succeeded. I prefer the latter caustic, for regarding 
the pultaceous phagedenic chancre as a chancre complicated with 
hospital gangrene, I treat it as I would the latter disease. The 
following is my method : I begin by making little rolls of charpie 
sufficient to cover the ulcer ; each of these is soaked in nitric acid, 
and applied over the diphtheritic layer, on which we press a little, 
then another is placed by the side of the first, in such a manner as 
to fill the ulcer. A layer of charpie is placed over this first dress- 
ing, then a compress, so as to make gentle pressure. This dressing 
is renewed twice in a day, and at each change the parts are bathed 
with wine, in which walnut leaves and the petals of the red rose 
have been macerated. In the milder forms I am content to satu- 
rate the charpie with a mixture of equal parts of tincture of iodine 
and water. In those more obstinate, M. Eicord recommends the 
application of a blister just above the ulcer, or a dressing composed 
of powdered cantharides. In his notes to the second edition of 
Hunter, in which may be found repeated his advice as to the treat- 
ment of phagedenic chancres, the above method is suppressed. Was 
it forgotten, or was it not rather owing to the fact that it did not 
sustain its first reputation ? I know not. I can say nothing of 
this method from experience having never employed it. 

The edges of the diphtheritic phagedenic ulcer are frequently so 
denuded and attenuated, that their adhesion seems impossible. If 
the ulceration result from an abscess, there may be considerable 
separation, and the skin become very thin, from the simple so- 
journ of the pus, without having been involved in the plagedenic 
action. Then, no matter what the extent of tissues to be sacrificed, 
a cutting instrument may be employed, the curved scissors being 
preferable, to excise neatly, and to give to the wound the form 
most favorable for cicatrization. It is desirable to avoid as far as 
possible the formation of scars, in certain regions, as they remain 
as stigmas of habits which the subject wishes not to be exposed. 
But when the enlargement of the ulcer is the result of phagedenic 
action, the knife is more injurious than beneficial, for instead of 
limiting the disease, it favors its extension, unless we resort to the 
cauterization of the wound inflicted. But would it not therefore 
be better at once to cauterize ? For this purpose M. Eicord pre- 



CHANCRE. 227 

fers the Vienna paste. He maintains that by this canstic we may 
not only limit its action to the parts which we wish to destroy, 
but we may also completely destroy the virulent surface, and pre- 
vent the too rapid inoculation of the new edges of the ulcer, by 
the interposition of an eschar, and a kind of vital reaction, the ab- 
sence of which, in some cases, is one of the principal causes of the 
ulceration. 

Whatever may be the variety of the phagedenic chancre, when 
it detaches the frasnum, and produces a fistulous track, a bridge, by 
excising the parts thus separated; and ulcerated, and which be- 
came diseased from contact, the cure is greatly expedited. A 
blade of the scissors is passed beneath the sinus, we then cut near 
the glans, and afterwards reset the portion which remains adherent 
to the prepuce. Immediately afterwards the whole solution of con- 
tinuity, in other words, the wound made by the operation and the 
remnants of the ulcer, should be cauterized. 

M. Puche employs the following solution in the case of a serpig- 
inous phagedenic chancre : 

^ . Tart. Fer. et Potas, 3 v. 
Aq. Oct. i. 

For fomentations. 

Internally, he administers the following syrup : 

$. Tart. Fer. et Pot. 3 v. 
Aq. Canell. 3 xiv. 

Syr. Sacch. Oct. i. 

Dose from five drachms to three and a half ounces a day, in a 'pint 
of tisane of gentian. 

This syrup is particulary beneficial when there is chlorosis or 
anemia in connection with the phagedenic chancre. 

Once I succeeded with the emplastrum de vigo in a very severe 
case of secondary serpiginous phagedenic ulceration, which re- 
sisted all other means. This ulceration occupied the external and 
lower part of the thigh, and the same side of the superior half of 
the leg. I then applied narrow bands of plaster, as in the case of 
atonic ulcers of the lower extremity. These bands were renewed 
every third day, and in less than fifteen days the phagedenic action 
was arrested, and the cicatrization far advanced. The success which 
I obtained by this method is favorable to its adoption in certain 
cases of phagedenic chancres. But, in order that this dressing par 
occlusion succeed, the chancre must be so situated as to permit its 
exact application. 

ACCIDENTS OF CHANCRE. 

PHIMOSIS AND PARAPHIMOSIS. 

Phimosis. — This exists when the glans cannot be uncovered by 
the prepuce. There is generally a prolongation, and more or less 
contraction of this envelope ; or the parts naturally covered by the 



228 "VTDAL ON VENEREAL DISEASES. 

prep ice are swollen, or there are tumors and excrescences which 
impede the movements of this envelope. Its opening is suffi- 
ciently large to permit the emergence of the glans in its natural 
state ; but tumefied, hypertrophied or covered with vegetations, it 
can no longer pass this opening. Phimosis is more or less com- 
plete, according to the contraction of the preputial overture. 

This condition of the prepuce may be congenital ; it may be 
produced by an irritation or ulceration, such as chancre. Most 
frequently it is the result of balanitis, rarely of urethral blennor- 
rhagia, except when complicated with an inflammation of the 
lymphatics or peri-urethral abscesses. With a chancre, we often 
find phimosis ; the former being surrounded with more or less in- 
duration, there is a thickening and want of flexibility ; the end of 
the prepuce sometimes resembles a shell covering the glans. The 
retraction necessary to uncover the glans then becomes impossi- 
ble, or dangerous, as it may give rise to a paraphimosis. Chancres 
are situated on the base of the glans, or more or less near the edge 
of the prepuce. If seated on the edge, and numerous, they may 
prevent the uncovering of the glans during their inflammatory 
turgescence, and at a later period by the cicatrices which follow, 
and which form a real stricture ; thence a permanent accidental 
phimosis. Phimosis may become permanent from bands and ad- 
hesions which unite the prepuce and the glans in an unnatural 
manner. 

The primary accidents are not alone the cause of phimosis : the 
eruptions called secondary, the mucous tubercle, more or less 
hypertrophy of the prepuce, a contraction, may render it less 
supple. The inflammations, chancres, and other lesions which 
produced a phimosis, may be aggravated by the phimosis itself; 
the effect here becomes the cause, and the complicative cause: 
thus, by an accidental phimosis, a certain degree of strangulation 
is produced ; this produces more or less obliteration of the prepu- 
tial cavity, and difficulty in the expansion of the inflamed tissues. 
Especially when the prepuce is inflamed, we sometimes find the 
skin of the penis drawn forward ; the glans, as it were, is pushed 
backwards, and the prepuce projects in front of it, sometimes, ac- 
according to Hunter, for the extent of three inches. Occasionally 
this pedicle is a little twisted. Sometimes it happens that the pre- 
putial mucous membrane yields more readily than the skin ; it 
then forms a kind of swelling, somewhat strangulated by a neck 
which is at the point where the skin naturally terminates. In 
both these cases the narrowing of the prepuce is considerable, and 
we cannot think of uncovering the glans. 

The inflammation of the prepuce, at first erysipelatous, may 
assume a phlegmonous character: whence the abscesses which 
open on the skin or in the preputial cavity, according as the ex- 
ternal or internal envelope yields. It often happens that both 
membranes yield equally ; perforation of the prepuce then takes 
place by a slough, or by an ulceration which proceeds from within 
outwards. Most frequently matters occur as Hunter has so justly 
remarked: the glans enters the orrtice of the prepuce and the 



PARAPHIMOSIS. 229 

ulcerations ; it fills the preputial cavity, and often so closely, that 
the pus secreted by these ulcerations cannot find a passage by its 
natural opening. A collection then forms behind the corona 
glandis, a kind of abscess, producing an ulceration, which extends 
both externally and internally, and penetrates the prepuce. This 
opening is almost always observed towards the end of the prepuce, 
which corresponds to the dorsum of the penis, and this, either 
because it proceeds from an ulceration or the separation of an 
eschar. When this opening is very large, the glans protrudes ; 
the end of the prepuce is carried downwards, causing a prominence 
at this part, and giving the penis a bifid aspect. Nearly the whole 
of the prepuce has been observed to be destroyed ; mortification 
likewise causes a true resection, a circumcision of the prepuce. 
There are other still more serious ravages ; the glans may like- 
wise suffer, either because the ulcer was at first seated on it, or 
because it spread from the prepuce so as to involve it ; indeed, 
after the prepuce is opened, a portion of the glans is found to be 
destroyed. This is now a serious case ; but it is still more serious 
when the urethra, the navicular fossa, and the corpus cavernosum 
are involved. 

PARAPHIMOSIS. 

Paraphimosis, or a strangulation of the penis behind the corona 
glandis by the ring of the prepuce, is an accident of grave import- 
ance, which may result from the inflammation accompanying 
chancres on the prepuce. We must distinguish between the para- 
phimosis which succeeds to an accidental or congenital phimosis, 
which is observed when the glans is forcibly uncovered, and who 
are attacked with a swelling of the penis ; in this latter case, the 
orifice of the prepuce, which before was sufficiently large to per- 
mit the movements of the prepuce on the glans, strangles the 
latter at its base. The first strangulation, that connected with 
previous phimosis, produces much the most rapid and serious 
effects ; it suddenly attains its highest degree of intensity ; for the 
strangulation is here formed by the ring which girts the penis, and 
by the penis, which, as it were, presses against the ring. On the 
other hand, when phimosis has not previously existed, the penis 
alone is strangulated ; as it swells, it comes gradually and slowly 
against the preputial ring, which was large enough to allow the 
movements of the penis in its natural state, but not when the latter 
has become preternaturally large. It will be well to remember 
this double mechanism of paraphimosis when we come to consider 
its treatment. 

When the ring closely embraces the penis, when the paraphi- 
mosis is irreducible and complicated with the inflammation con- 
nected with chancres, the glans becomes more and more engorged, 
the cavernous body becomes indurated, and there is a struggle 
between the parts strangulated and those which produce the stran- 
gulation. The latter are generally the first to yield ; in fact, the 
ring formed by the prepuce ulcerates, and becomes mortified ; the 



230 VIDAL ON VENEREAL DISEASES. 

two layers, the mucous and cutaneous, of the prepuce are separ- 
ated. But the patient does not always obtain from these morbid 
changes a relaxation very complete, and the penis does not return 
to its normal condition, for the resolution is slow ; adhesions are 
established, which cause more or less apparent deformity, and 
which are attended with greater or less inconvenience. 

Treatment. — 1st. Treatment of phimosis. — When phimosis is acci- 
dental and highly inflammatory, when its primary cause is a 
chancre, the treatment is attended with very great difficulties. In 
the first place, we should resort to emollients, and to antiphlogis- 
tics, when the inflammation is severe, the swelling considerable 
and tense, when there is decided redness. If the subject be young 
and vigorous, we should not hesitate to commence by a copious 
general blood-letting. Leeches are also indicated ; but there is 
danger of the inoculation of their bites, and an aggravation of the 
inflammation from these trifling wounds. They should therefore 
be applied at a distance from the penis — as, for example, on the 
perineum and the inguino-crural regions. We should not be satis- 
fied with direct antiphlogistics, but should also act on the bowels, 
with saline purgatives, such as the citrate of magnesia, and Seidlitz 
water ; after which we may resort to general bathing, cataplasms 
covered with Goulard's extract ; injections between the prepuce 
and glans, at first of a narcotic and emollient, and afterwards of 
an astringent character. These injections may be rendered caustic, 
especially when we have reason to suspect that it is caused by a 
balano-posthitis. 

If these means do not succeed in subduing the inflammatory 
accidents, if the pain is severe, and there is a difficulty in urinat- 
ing, if there is an accumulation of pus within the prepuce, and this 
envelope is threatened with a perforation, and especially if con- 
genital phimosis exist, many practitioners would imagine that 
there were sufficient reasons for resorting to an operation ; some, 
indeed, would not require so strong an argument for using the 
knife. For my own part, I could never perceive the absolute 
necessity for performing this operation ; I am afraid of thus in- 
creasing, instead of diminishing, the inflammation by the incision, 
a result which often happens. If it is decided to operate, to make 
an incision, it should not be limited to a very small extent of the 
prepuce ; we should not open the abscess only, which is sometimes 
seated towards the base of the glans, for thus the accidents may 
not be at all arrested, and after their disappearance, the phimosis 
may return. The incision, then, should extend from the edge of 
the prepuce to the base of the glans. Still we have reason to 
apprehend that the wound thus made may be transformed into a 
vast chancre. It will be seen, therefore, that the advantages of 
the operation do not counterbalance its inconveniences, for the 
chancre in attacking the wound, is not confined in its ravages to 
the localities first invaded. For my own part, I always rely upon 
antiphlogistics, 'both direct and indirect. True, after the disappear- 
ance of the accidental phimosis, I have occasionally observed 
that a portion of the glans has been destroyed. These ravages 



PARAPHIMOSIS. 231 

have likewise been observed by surgeons who have been in haste 
to operate. The prepuce has also been found perforated, not- 
withstanding the use of antiphlogistics, of topical applications and 
injections. For the most part, patients have come under my care 
at an advanced period of the disease. After the cicatrization of 
chancres, and the subsidence of the inflammation, it is easy to 
repair more or less perfectly the deformity resulting from this loss 
of substance in the prepuce. I repeat it, the situation of the prac- 
titioner is here very embarassing ; I have given my experience, 
and I will not indulge in any criticism of the methods adopted by 
my opponents. 

After the complete cicatrization of chancres, and the cessation 
of the inflammation, the phimosis remains when the prepuce has 
not been divided. This phimosis is congenital, or rather it is an 
accidental phimosis become permanent by the contraction result- 
ing from the cicatrix. In both cases, after the disease has been 
cured, it is desirable to remove the deformity and thus prevent the 
chances of a new inoculation, for it is admitted that subjects af- 
fected with phimosis are more frequently infected than those whose 
glans is uncovered. 

2d. Operation for Phimosis. — I will not here describe all the meth- 
ods which have been proposed.* The excision of the prepuce, 
circumcision, having been commonly adopted, I will consider this 
operation. I add to the ordinary proceedings means of uniting 
the parts, as, no matter what method we employ, after the excision 
of the prepuce, the skin retracts towards the pubis, and its mucous 
membrane is left much exposed ; a very large wound then re- 
mains, which inflames, suppurates, and is often the source of 
hemorrhage. Instead of excising this exposed mucous membrane, 
I reverse it so as to apply it higher on the skin, when I unite it 
by sutures, or, what is preferable, the spring sutures. The suture 
may be applied as the parts separate, or, what is better, the threads 
may be passed before excision is made, which may be performed 
according to two different methods. 

A. First Method. — A line is traced with ink on the skin of the 
prepuce, in the direction of the corona glandis, having a lozenge- 
shaped form. This line may be traversed with points of suture. 
The skin should be drawn neither in front nor behind the glans. 
With a pair of dressing or spring forceps, we seize the dorsum of 
the penis, near the frsenum, and, in an oblique direction, the whole 
of the prepuce in front of the black line. Whilst the operator 
with the forceps stretches the prepuce a little forwards, an assist- 
ant seizes the sheath of the penis near its root, and draws gently 
towards. the pubis. The threads are then passed transversely, 
that is, by crossing the forceps on the dark line, they will be five 
millimetres from each other. The extremity of the prepuce seized 
by the forceps is still drawn a little forwards ; then, with a pair 
of strong scissors, such as are used for hare-lip, the prepuce be- 

* Vide my Traite de pathologie externe et de medecine operaioire, t. y. 3d ed. I 
transcribe from this work the description of the proceedings which I employ. 



232 VIDAL ON VENEREAL DISEASES. 

tween the threads and the forceps is at once divided. This cir- 
cumcision being completed, the cavity of the prepuce is more or 
less opened, we see that the threads are passed on the glans, and in 
a direction perpendicular to the meatus urinarius. These threads 
are then divided in the middle, and each forms two handles, one 
on each side of the glans. Thus, if four threads are passed, we may 
make eight sutures, four on each side. I use flat needles, lancet- 
shaped, and very fine. I remove the sutures on the fourth day. 

This method is much more easily executed, if, instead of first 
passing the threads through the prepuce, we push the needle no 
further than is necessary to discover its point on the opposite side 
to that on which it was entered. The needles then cross the 
direction of the forceps, and the incision is made between them. 
The incision is then more neatly and easily made. After the ex- 
cision of the prepuce, the body of the needles is seen traversing 
the preputial cavity ; each needle is drawn by its point, and its 
other extremity, then presenting to the surgeon, enables him to 
grasp the thread. Each needle being thus seized, the operation, 
in other respects, is such as I have described. 

B. Second Method. — The black line is traced, as in the first 
method. A grooved director is introduced within the prepuce, 
and its handle confided to an assistant ; he inclines it to one side ; 
the beak of the director causes the prepuce to project in an oppo- 
site and distant direction, at the point against which it presses. 
With the same kind of needle as that before used, a thread is 
passed between this instrument and the glans. There is then a 
handle of thread passed in the direction of the black line. The 
needle is first entered towards the dorsum of the penis. The 
sound is pushed a little more towards the frasnum, about two lines 
from the first stitch, and the same needle and same thread is passed 
behind the instrument ; finally, the prepuce will be surrounded 
with a suture with points passed. The thread describes a spiral 
shape, and forms a handle within and without the prepuce. The 
forceps should be applied as I shall presently describe ; and with 
large scissors the extremity of the prepuce between the forceps 
and the spiral represented by the thread, is removed. The latter 
should be long, as, after the circumcision has been performed, each 
loop divided on the cutaneous and the mucous surface, will furnish 
two ends of thread, which will serve to make a stitch. 

I admit that it requires much time to execute the proceedings ; 
but they possess unquestionable advantages. The first results, so 
far as its appearances are concerned, could not be more satisfactory. 
After the operation no dressing is required ; a compress saturated 
with cold water alone, is applied to the penis ; and we have no 
hemorrhage to dread. Now, we know that hemorrhage is a very 
frequent result of the other methods. On the fourth day the su- 
tures are removed. After every operation performed on the penis, 
the process of cicatrization may be impeded by erections. But the 
application of a few leeches to the perineum, with the use of pills 
of camphor and opium, and some attention to regimen, will guard 
.against this accident. 



PARAPHIMOSIS. 233 

0. Third Method. — Use of the spring sutures {ser res-fines). — The 
spring sutures were first used for the purpose of uniting the wound 
made in the operation for phimosis. I have stated that the sutures 
were to be removed on the fourth day. Since that I have re- 
moved them at an earlier period ; sometimes I have left them for 
only twenty -four hours, and this too without interfering with the 
union of the parts. I have therefore asked myself, if, for so short 
a time, it was necessary to inflict the additional pain of the suture, 
and if the little fingers could not patiently keep the lips of the 
wound united, since union can take place so promptly. I then 
had the spring sutures made by M. Charrie're. These instru- 
ments, which were of steel, being in my opinion too heavy and 
too difficult of retention in the same place, I furnished M. Luer 
with the idea of spring sutures, serves-fines, here represented : a, is a 




spring suture, the branches of which are still uncrossed; 5, branches 
crossed, instrument closed ; c, instrument opens when pressure is 
made on the great inferior ring ; d, the handle which enables us to 
seize the instrument. These are small spring sutures. M. Luer 
makes them at least one half smaller. Oculists find them very 
serviceable in their operations on the eye-lids. When the smallest 
size is used, a jporte serre-fine becomes necessary, for the fingers 
cannot retain their hold, and they conceal the point to which we 
would apply them. M. Luer has contrived a very ingenious 
instrument for the above purpose. In order to obtain a complete 
and speedy union, it is desirable that the skin and mucous mem- 
brane be perfectly applied to each other. Whilst the surgeon 
takes hold of the instrument and presses on the large ring so as to 
open it, the assistant, with two small dissecting forceps, one in 
each hand, applies the skin and mucous membrane accurately to- 
gether, and when they are nicely adapted to each other, the sur- 
geon applies the instrument, after which the pressure is discon- 
tinued. The two membranes may also be well adjusted to each 
other, by pressing on the middle of the wound, and according to 
its direction, with a small grooved sound. We thus replace the 
cellular tissue which has a tendency to portrude, and prevent it 
from interfering with the union of the wound. Indeed, if a por- 
tion of the cellular tissue interpose between the lips of the wound, 
union by the first intention is impossible. I will not disguise the 
fact that this method is difficult and delicate in its application ; 
but a cure may be thus obtained in twenty-four or thirty hours. 
Such success has attended not only my own practice, but that of 
all my confreres who have tried to apply these instruments with care. 
Permit me to refer to what constitutes a real improvement in 
the art of correcting the deformities of the penis. When I en- 
tered on the service of the Hopital du Midi, circumcision was per- 
formed, according to the method recommended by M. Kicord, who 



234 VIDAL ON VENEREAL DISEASES. 

then stated in Ms work: "The results of circumcision after my 
method, have appeared to me more favorable than those obtained 
by other proceedings. A cure has been effected in from twenty 
to twenty-five days."* 

Now a cure has been obtained with these instruments in from 
twenty to twenty -five hours. 

3d. Treatment of Paraphimosis. — "We shall commence with sed- 
atives, and antiphlogistics, as recommended in the treatment of 
inflammatory phimosis, connected with more or less strangulation. 
Before we attempt reduction, it is well to remember the two varie- 
ties of paraphimosis which I have established, that which has been 
preceded by phimosis and that which may produce it, the glans 
being naturally uncovered. It is certain that if we reduce para- 
phimosis on the subject who has congenital phimosis, he will have 
a vicious conformation, at the price of very severe pains. It is 
better then to operate, and we should not only incise the ring by 
which strangulation is produced, but extend the incision equally 
in front and behind the glans. This is the course to be pursued 
when paraphimosis is irreducible. In other cases, punctures over 
the tumefied and cedematous parts, the application of cold com- 
presses, and circular compression, produce generally good effects. 

M. Seutin has proposed, for the purpose of acting on the glans, 
reducing its volume, and favoring reduction, the use of forceps 
with spoon-like ends, which will closely embrace this organ, and 
effects complete compression, more uniform than that produced by 
the fingers of the surgeon. In every case when the disease is com- 
plicated with chancre, the latter should also receive our attention, 
and we should not be confined to local treatment. 



CHAPTER VI. 

BUBO. 



Bubo is an engorgement of the lymphatic vessels, and princi- 
pally of the lymphatic ganglia ; its most frequent cause is the 
action of the syphilitic virus on these organs. 

Seat. — As the word bubo denotes, it is with the engorgement 
of the ganglia of the groin that we are now chiefly concerned. 
However, almost all the ganglia which have their efferent vessels 
not far from the skin and the origin of mucous membranes, may 
become engorged as the result of inoculation from some point of 
the integuments. Besides the buboes of the inguinal region, those 
of the neck of the axilla, and the fold of the arm, are those which 
are most frequently observed. In the groin there are still differ- 
ences of seat : thus, buboes may be above or below Poupart's liga- 
ment ; the first we called crural; the others are called abdominal; 
when the latter are near the median line, the root of the penis, 

* Traite pratique des maladies veneriennes, p. ^775. 



bubo. 235 

they are known as pubic buboes. I shall soon speak of the in- 
fluence of the position of chancres on the seat of buboes. 

Causes. — Sex seems here to exert a decided influence ; at least 
twice the number of buboes are seen in the male than the 
female. Different grades of society also show a great disproportion ; 
thus the working classes, those who are careless of their persons 
during the existence of a chancre, and those who are engaged in 
very hard labor, are the persons most liable to be affected with 
chancre. To be persuaded of this difference we have but to com- 
pare the patients treated in hospitals with those in private prac- 
tice, and note the predisposing causes. 

The syphilitic virus is the principal cause of buboes ; but it 
does not always reach a ganglion in the same manner. It may in- 
volve a gland after having ulcerated or inflamed the tegumentary 
surface with which it comes in contact, or indeed after a traumatic 
solution of continuity, or even without any alteration of the in- 
teguments, in other words by physiological absorption. This would 
imply that a bubo may follow a chancre, a blennorrhagia, an in- 
oculated wound, and may even occur without any of these lesions, 
that is to say it may be primary (d'emblee). 

Chancre is certainly the most common starting point of a bubo. 
Hunter established this fact completely. M. Philip Boyer main- 
tains that chancre is always followed by bubo, which is equally 
incorrect with the opinion entertained by others, that there can 
be no syphilitic chancre without a bubo. 

Bubo is generally observed during the earliest stages of chancre, 
that is during the first week ; it may not occur until one or two 
months after the natural disappearance of chancre, or after its ci- 
catrization has been effected by remedial measures. I do not be- 
lieve that the speedy cicatrization of a chancre has any particular 
connection with the production of a bubo. Occasionally a very 
long time passes between the cicatrization of a chancre and the 
appearance of a bubo, proving that there is even here a period of 
incubation. 

In the male, buboes most frequently follow chancres on the pre- 
puce, whilst in the female they follow those seated near the meatus 
urinarius. The position of a chancre on the penis may have an 
influence on the seat of a bubo. The connection here, however, 
is not so precise as to furnish a categorical answer to the question ; 
given the seat of chancre, what will be the seat of bubo ? It is 
known only that bubo generally occurs on the same side as the 
chancre ; thus the ulceration of the left side of the prepuce is fol- 
lowed by a bubo on the left side of the groin, and vice versa. How- 
ever, the contrary may happen from a decussation or anastomosis 
of the lymphatics. When there is a chancre on each side of the 
prepuce, there is generally a bubo in each groin. A chancre of 
the fraenum gives rise indifferently to a right or left bubo, some- 
times to both. Notwithstanding all that has been said, even nu- 
merous chancres may exist without being followed by bubo, as is 
at present exemplified in Ward No. 10 of my service. It must be 
well understood that we are not to confound with buboes ganglia 



236 VIDAL OjS" venereal diseases. 

only a little more enlarged than natural, and which of course may 
have existed without any manifestation of chancre. 

Blennorrhagia is less frequently the starting-point of bubo than 
chancre, and when adenitis is developed, it is then said to be the 
result of sympathy or extension of the irritation. A really syphi- 
litic bubo, arising from the absorption of the virus, it is said can 
only follow a urethral chancre. This hypothesis I have already 
combatted, as I have shown that there may be a really syphilitic 
blennorrhagia without a urethral chancre. 

Bubo may also result from the physiological absorption of the 
virus ; that is, without having been preceded by the three orders 
of lesion already indicated, viz. without inflammation, ulceration, 
or solution of continuity. This is proved by analogy, by authori- 
ties, and by facts. It is well known that a vast vascular network 
covers the whole body ; the virus penetrates this network ; it is so 
subtile that it may traverse the most external layer of the integu- 
ments, without any solution of continuity, and, as it is called, by 
imbibition. The network to which I have alluded sends out 
branches of lymphatics, which become loaded with virus, and 
bear it to the vessels and the glands. The whole of this route 
may be traversed without any lesion of the conducting vessels, 
because they do not react. But if the first network reacts, we ge- 
nerally have a chancre ; if the vessel, a chancrous inflammation 
of the lymphatics ; if the gland, a chancrous adenitis, a veritable 
syphilitic bubo. Some writers on syphilis do not fully admit 
this ; they acknowledge only that a lymphatic vessel may be tra- 
versed by the virus without suffering the least injury. Now the 
same observation applies to the other tissues. Analogy, indeed, 
proves that the virus may pass from the skin to the ganglion 
without wounding any part, and the facts upon this point are con- 
clusive. Thus, when variola is not inoculated (and it is no long- 
er inoculated), how does the virus enter the system ? By the same 
avenues as the syphilitic virus, and no previous solution of con- 
tinuity is required. Does not the virus of glanders sometimes 
affect animals and man without any previous solution of con- 
tinuity? Is there not a glanders d'emhUe? Consult on this sub- 
ject the most weighty authority — Hunter. Now, Hunter admits 
the bubo d'emhlee in the sense received by us. 'Twas particu- 
larly when treating of buboes that he pointed out the four surfaces 
by which pus may be absorbed : 1st, by an ulcer ; 2d, by an in- 
flamed surface ; 3d, by a traumatic surface ; 4th, by a common, 
that is to say a sound surface. These three kinds of absorption 
are not merely theoretically indicated only. Hunter fully appre- 
ciated them, and studied them in view of facts. He clearly show- 
ed that absorption most frequently occurs by an ulcerated surface, 
and that by sound surfaces it is least frequently observed. On 
this point the English surgeon has shown an extreme distrust and 
the greatest hardihood. 

He advises, for example, that women should be avoided, as it 
is never known whether they are or are not affected with blennor- 
rhagia ; he remarks that before an opinion is formed, they should 



BUBO. 237 

be most carefully examined, and then we shall often discover that 
a small chancre is the cause of the infection, a circumstance that 
has more than once happened. " We should," he observes, "pay 
especial attention to every circumstance connected with a case of 
this kind." (p. 480.) Hunter, moreover adds, that every engorge- 
ment in the groins is not a venereal bubo. Thus, we here find a 
great genius, a keen and accurate observer, who admits the exist- 
ence of the primary bubo. "We may assert that this doctrine is 
now becoming again in vogue, since this form of bubo is admitted 
not only by those who have always sustained this opinion, but 
by the disciples of M. Eicord ; for example, by M. Beynaud (de 
Toulon) and M. Gibert. M. Keynaud declares very positively that 
he has treated persons who, after a suspicious intercourse, had fre- 
quently examined their penis, without discovering anything ; and 
that they became affected with buboes which were followed by 
very decided consecutive accidents (p. 55). M. Gibert positively 
observed a case of primary bubo, the matter of which he success- 
fully inoculated. M. Eicord very simply objects to this, that M. 
Gibert deceived himself, or was mistaken. Observe that this reply, 
especially when politely stated, might be made to every observer ; 
to MM. Lagneau, de Castelneau, Cazenave, Baumes, &c. In the 
work of the last-named author, cases sixth and seventh leave no- 
thing to be desired on this subject, since they were inoculated with 
success. 

[During our recent visit to London, Mr. Lane very politely 
showed us, at the Lock Hospital, two cases of the bubo oVemblee. 
In one of these cases inoculation had produced the characteristic 
pustule. The brief notes of the case, as made under the supervi- 
sion of Mr. Lane, are as follows : — Thomas Hughes, get. 22, admit- 
ted into the Lock Hospital, May 5th, 1853. Six weeks previously 
had last connection. At the time of our visit, 26th May, he had 
had a bubo for a month. No trace of a sore on the penis or any 
other point. Both Mr. Lane and myself, after diligent inquiry, 
could detect no other symptom. Matter from the bubo was inoc- 
ulated on the left thigh on the 21st May. On the 26th ; character- 
istic pustule, which we saw, was perfectly developed, and Mr. L. 
directed it to be cauterized at once. Mr. L. informed us that cases 
o$ primary bubo not unfrequently came under his observation, but 
that this was the first instance in which he had produced positive 
results or inoculation. M. Eicord, in his Treatise (Am. ed. pp. 187, 
190), has recorded eight cases of the bubo d'emblee ; and Dr. Judd, 
in his works on the venereal, has detailed several of the kind. M. 
Eicord, at pp. 74, 75, of his Treatise (Am. ed), has given us incon- 
testable proof of the existence of this form of bubo. He quotes 
authority after authority in support of what, in his Letters 
(XXV.), and his Notes to Hunter, (2d ed, p. 521,) he treats with 
ridicule ; indeed, in referring to the successful inoculations of M. 
Gibert, he very complacently observes, that he either deceived him- 
self, or was deceived (M. Gibert s'est trompe ou a ete trompc) ! 

Dr. Graves, in his Lectures (Dub. ed. 1848, vol. ii. p. 385), quotes 
from Dr. Eoe's Eeport of venereal patients treated in the 3Sth 



238 VIDAL ON VENEREAL DISEASES. 

Eegimental Hospital, the following: "Buboes were often seen 
without an j ulcers on the penis," &c. M. Kicord admits in his 
Treatise, p. 222, Am. ed., the devolopment of abscesses formed by 
the imbibition of matter from an adjacent chancre, yet, in his Let- 
ters (XX Y.), he denies the possibility of such imbibition ! — Gr. C. B.] 

For my own part, I have seen several instances of the primary 
bubo. As I did not inoculate the primary accident, I waited 
the development of constitutional disease. In Ward No. 11 
there was a case of double bubo, on a subject whose glans penis 
was quite uncovered ; he had had these swellings for five days ; 
he watched himself carefully ; the buboes were positively the first 
manifestations of the disease ; he had neither a discharge nor a 
sore. I was enabled to watch this patient for a long time, and I 
saw a papular eruption developed. Another patient entered with 
a bubo still more recent than the first ; there was nothing in the 
antecedent circumstances that could lead to the suspicion of any 
other primary symptom; only, he described perfectly a roseola 
which had disappeared. This I did not see. But a swelling after- 
wards appeared in the superior maxillary bone, which resulted in 
necrosis, and I extracted a fragment of bone to which were at- 
tached two of the teeth. The separation of the sequestrum, and 
the healing of the wound, were remarkably rapid, under the influ- 
ence of the iodide of potassium. 

Besides the buboes from absorption of the syphilitic virus, it is 
admitted that there are those produced by an extension of irrita- 
tion or inflammation, or by sympathy, independent of syphilis. 

The virus, having acted on the whole system, may cause an en- 
largement of the glands and establish a consecutive bubo. In 
fine, bubo is said to be inflammatory or indolent, acute or chronic, 
according to the prevalence or absence of the phenomena of in- 
flammation. Still other divisions have been made ; these it is un- 
necessary for me here to notice, as I am now considering these 
swellings in an etiological point of view. 

Symptoms. — I shall first describe the more general symptoms ; 
in treating of the varieties, and especially of inflammatory bubo, 
I will complete the sketch. 

Bubo is occasionally preceded by febrile excitement ; this 
ceases only after the appearance of suppuration. In corpulent 
subjects, especially females, fever sometimes exists for several days 
before a bubo is suspected, particularly when it is small. The 
tumor is generally of an oblong shape, its grand axis following 
the direction of the bend of the groin. In other situations, as the 
elbow and the axilla, it assumes a globular form. If the swelling 
consist of one gland alone, if it be already inflamed, it is of a reg- 
ular uniform shape ; if, on the contrary, several glands are affected, 
and inflammation be still absent, the swelling is more or less ir- 
regular in form. Sometimes the tumor is divided into two segments 
— a superior, and an inferior; this disposition is observed when 
the very dense cellular tissue at the bend of the groin has resisted 
the development of the gland ; it then produces in this situation 
a kind of strangulation, a depression, and the tumefaction takes 






bubo. 239 

place on the side of the abdomen, or the thigh, where the adhesion 
of the skin offer the least resistance. 

Varieties. — Buboes have been divided into many varieties, ac- 
cording to the phenomena, and the symptoms which they present. 
I shall describe but two varieties ; the inflammatory, and the 
non-inflammatory or indolent bnbo, and in my description of these, 
I shall point out the characters of the sub-varieties. 

1. Inflammatory Bubo. — Bubo is generally the result of the ac- 
tion of the syphilitic virus on a portion of the lymphatic system ; 
it is the huho from absorption. But this absorption may occur on 
an ulcerated, an inflamed or a sound surface. In the latter case, 
it is called primary bubo. I have already stated, that this kind 
of bubo was admitted by Hunter, that it was consistent with 
reason, and that it had been established by clinical facts, and by 
experiment. Whatever the surface of the absorbtion, the virus 
generally passes .at once to the lymphatic glands, by their afferent 
vessels. These vessels are generally insensible to the poison which 
they carry ; if they do re-act, a virulent angioleucitis is developed, 
which may be regarded as a bubo of the lymphatic vessels. It is 
well here to note the possibility of the virus passing through the 
lymphatic vessels without necessarily infecting the vessels them- 
selves, a fact admitted by those writers on syphilis who deny the 
existence of the primary bubo, and this too for the reason that the 
virus cannot penetrate our tissues unless by means of an ulcer ! 
Now we here find this same virus traversing the lymphatic ves- 
sels, leaving them, for the most part, perfectly sound. 

It has been maintained, that in the bubo from absorption one 
gland only is affected, except in the case of very large chancres, 
which may communicate with a great number of lymphatic ves- 
sels. Nevertheless, there is in my service a patient affected with 
chancres on the penis ; he inoculated himself with these chancres 
through a crack on his finger ; at this point was a chancre almost 
imperceptible, and yet it was followed by a bubo at the bend of 
the arm, and in the axilla. We here see that the virus passed 
far beyond the first gland that it encountered. Another erroneous 
idea is, that when the virus is once beyond the lymphatic vessel 
and gland, it can be no longer inoculated, or transmitted. When 
once this virus has entered the circulation, it may still produce 
effects, even on the individual in whom it has been absorbed, but 
not on another person, for these effects, which are secondary acci- 
dents, cannot be inoculated, nor are they contagious. This serious 
error, against which clinical facts daily protest in vain, has been 
completely refuted by experiment. It has, indeed, been proved 
that a sound person may contract syphilis not only from the mor- 
bid secretions furnished by secondary accidents, but from the 
blood of the individual affected with these same accidents. Be- 
sides, who will say that the virus can reach the gland only by 
means of the lymphatic vessels ? Every circumstance goes to 
show, on the contrary, that this poison may directly enter the cir- 
culation, and through the latter, reach every part of the system. 

Bubo may likewise occur independently of any specific syphilitic 



240 YEDAL ON VENEREAL DISEASES. 

action ; it is then maintained that the inflammatory radii from a 
chancre or an inflamed surface involve the glands ; in which case 
it is called bubo from extension. The sympathetic bubo should be 
produced by an irritation reflected from the point primarily affected 
to the gland. We may remark in passing, that this sympathetic 
reaction has been singularly abused. That bubo may be produced 
during the existence of a chancre or an inflammation of the integu- 
ments from which lymphatic vessels arise leading to the affected 
gland, can be admitted according to our general ideas of morbid 
sympathies ; but it is difficult, if not impossible, to acknowledge the 
sympathetic bubo without a starting point. For example, when 
buboes have been observed, without any previous lesion on the 
genital organs, without ulceration or inflammation, it has been pre- 
tended that they were sympathetic ! But sympathetic of what ? 
Where is the starting point of this sympathy ? What directs it to 
the gland ? They conclude by answering, coitus, a single act of 
sexual intercourse ! This arises from denying the absorption of 
the syphilitic virus by a sound surface, in other words from closing 
their eyes to facts ! 

However it may be, buboes by extension, sympathetic buboes, 
can only be, I repeat it, inflammatory accidents, and not syphilitic ; 
compared with buboes by absorption, they may be regarded as 
benign, for they contain no virus, and are not inoculable, as is the 
case with buboes by absorption. It will be remarked that buboes 
by extension, by the propagation of the inflammatory foci, those 
that are regarded as the most common among benign buboes, occur 
precisely in those cases where chancre is but little inflamed, often 
when it is cicatrized, and almost never when the ulceration is really 
complicated with inflammation. Observe what occurs after opera- 
tions on the penis, such as extirpations, ligatures, cauterizations 
of excrescences, cauterizations sometimes deep, incisions, excisions 
of the prepuce immethodically made ; now these lesions, each of 
which always produces an inflammation more severe than common 
chancre, are yet followed by no adenitis, by no bubo from exten- 
sion or sympathy ; whence I conclude that there is nothing more 
rare than what is called benign bubo, that is, adenitis, a simply inflam- 
matory adenitis, either from extension or sympathy. I believe 
even that the last, having no starting point, is entirely hypothetical. 

I proceed to describe the several phases of inflammatory bubo. 
We shall find even here, sub-varieties which have been separately 
described by certain authors. Inflammatory bubo is sometimes 
preceded by a fever, which continues whilst the swelling is in- 
creasing. We have then, as I have already stated, primary bubo. 
The patient complains of an unusual sensation in the region which 
is to be the seat of the inflammatory tumor ; to this succeeds a 
pain," or rather it extends along the thigh ; there is pain and diffi- 
culty in motion. The gland or glands are tumefied ; at first they 
retain some mobility, which in a short time is lost. The phleg- 
monous period has already commenced ; for, at the same time that 
the glands enlarge, in the majority of cases the cellular tissue 
becomes involved in the inflammation, the progress of which is 



BUBO. 241 

then still more rapid. The tumor presents an elastic feel, which 
differs from the indurated thickening of glands and cellular tissue. 
The skin is of a deep violet red color over the centre and around 
the tumor. The pain is generally exasperated and shoots in dif- 
ferent directions, or it may remain unchanged. Its violence does 
not always correspond with the severity of the inflammation. In 
fact, we may yet hope to disperse these tumors and prevent sup- 
puration, especially if the most absolute repose be observed. 

The inflammatory phenomena are more decided and produce 
greater reaction when the glands affected are deeply seated ; their 
enlargement is then prevented by aponeurotic layers which bind 
them down, and produce some symptoms of strangulation. If the 
inflammation continue, as is most frequently the case, pus forms, 
and then we have a suppurating bubo. In the majority of cases the 
matter forms in the cellular tissue, which becomes agglomerated ; 
fluctuation is then easily and promptly detected ; for the matter is 
more superficial and the abscess is unilocular. The skin is of a 
deep violet red color. When the suppuration, instead of being 
peri-glandular is intra-glandular, the pus may at first form several 
little foci in the organ ; its presence is then difficult of detection 
on account of this circumstance, and because it is more distant 
from the surface. It afterwards becomes collected in a single 
cavity hollowed out of the gland, and beneath a certain thickening 
of the parts we may perceive fluctuation, which becomes more 
evident when the intra-glandular foci communicate with the pus 
of the cellular tissue surrounding the ganglion. 

When pus has formed and become collected, both general and 
local excitement cease, and the movements of the thigh are less 
difficult. But the skin becomes thin and bare, of a deeper color, 
and if in the first stage of suppuration, some hope may still remain 
that the tumor may disappear without any solution of continuity, 
this hope is now entirely lost ; indeed, if the tumor be not opened 
it will open spontaneously. When the inflammation has been 
severe and acute the pus has the qualities of what is called good 
pus, phlegmonous pus ; if the inflammation has progressed rather 
slowly, and if it has been, as it were, arrested from time to time, 
as often happens when glands are inflamed, the pus is then thin, 
mal-assimilated, and filled with coagula. The pus may assume this 
double character when there has been a simultaneous suppuration 
of the gland and the cellular tissue by which it is surrounded. 
In all cases it may be more or less mixed with blood, occasionally 
it happens even, that the cellular tissue, or peri-glandular tissues, 
contain nothing but blood. 

Whether we do or do not interfere, though the tumor be 
opened early or late, the solution of continuity may assume the 
characters of chancre ; we have then what is called glandular 
chancre, which may present the different aspects that have served 
to establish the varieties of chancre. Thus this solution of con- 
tinuity may have the aspect of common chancre, or it may be 
more or less indurated, and thickened at its base and borders, cor- 
responding to the indurated chancre ; finally, mortified portions 

16 



242 YIDAL OX VENEREAL DISEASES. 

may be detached, the ulceration spread rapidly over one or several 
points, and resist all treatment : consequently, we should have the 
phagedenic chancre in all its different forms ; and here the same 
hygienic circumstances shall prevail, the same idiosyncrasies, the 
same therapeutic measures, which exerted an influence over the 
characters assumed by the ulceration, absolutely as I have de- 
scribed when considering the causes of the deviation in the form 
of what is called regular chancre. 

If the bubo be opened with a bistoury or lancet, if the opening 
be made at a proper time, and in the manner that I shall hereafter 
describe, there is a strong probability that the skin will contract 
its natural adhesions, and that the wound will soon become healed, 
without leaving any trace of deformity. If, on the contrary, we 
wait for the swelling to open spontaneously, if it be opened at too 
late a period, or in an improper manner, the skin will not become 
adherent, or it will be but imperfectly re-established : more or less 
of it will slough, and there will be a great loss of substance, or 
many openings, which will remain a long time fistulous. In both 
cases, the reparation of the wound will be slow, an unequal, de- 
formed, and strongly-marked vicious cicatrix will remain, to 
remind the patient of an event which, in the majority of cases, he 
would prefer should be unknown. 

2d. Non-inflammatory or Indolent Bubo. — This generally consists 
of several enlarged glands, which are movable, not painful, and 
do not, at the commencement, present any phenomena connected 
with true inflammation, except the increased size. A great im- 
portance has been attached to bubo in forming the diagnosis of in- 
durated chancre : M. Eicord even denominates it the necessary 
companion of this disease.* But he must know that a similar 
glandular enlargement may be observed in strumous subjects who 
have never had a chancre ; it may exist in the other varieties of 
chancre, in that called regular common chancre, which is regarded 
as deprived of all specific induration ; add to this, the fact that 
this same engorgement differs in no respect from consecutive bubo, 
since it exists in connection with indurated chancre, itself an indi- 
cation of the existence of the diathesis, being observed also, with 
the train of accidents called constitutional, and the value of the in- 
dolent bubo in. the diagnosis of syphilitic ulcerations is materially 
diminished. The indolent bubo, consecutive or primary, may 
assume an inflammatory character ; but its pus is not considered 
inoculable. 

Diagnosis. — We are now particularly concerned with inguinal 
bubo. Let us first exclude hernia, aneurisms, and abscesses, by 
congestion, the tumors produced by which are easily distinguished 
from bubo. The marks of some wound, or laceration, certain 
cutaneous inflammations, a furuncle at some point corresponding 
to the distribution of some lymphatic vessels leading to the glands 
of the groin ; the knowledge of these lesions will prevent us from 
confounding the glandular engorgements which sometimes result 

* Notes to Hunter, p. 552, 2d ed. 



BUBO. 243 

from them, with syphilitic buboes. The difficulties are not great 
when, with the bubo, other syphilitic accidents coincide ; if the 
latter are consecutive, the bubo is constitutional, indicative of the 
diathesis ; if the accidents are primary, bubo might be indolent in 
the case of indurated chancre, or inflammatory in the case of regu- 
lar, common chancre. The difficulty is real, and not easy to be 
surmounted when we cannot discover the starting point of the 
inflammation which has invaded the gland, when there is nothing 
on the integuments to indicate that the virus has penetrated the 
system, when, in fine, there is a primary bubo. Some have 
thought that these difficulties might be obviated by resorting to 
inoculation, which should produce a chancre, in the case of a 
syphilitic bubo, and which will fail if the contrary be true. But 
this proceeding cannot be adopted except where suppuration is 
already established ; it is important to decide before this event has 
happened, and even when it has, inoculation is difficult and uncer- 
tain. Indeed, in the case of a true syphilitic bubo, suppuration 
may have invaded but the cellular tissue surrounding the gland, 
when it is supposed that the gland itself has suppurated. In such 
a case inoculation would lead to no result, for the pus of the gland 
alone contains the virus. If we pass through the cellular tissue, 
and reach the suppurating gland, we cannot be sure of obtaining 
the virus, as the bubo may be composed of two glands, each of 
which may contain different kinds of pus ; the matter obtained 
may come from the gland, which does not contain specific pus, 
thence another failure of inoculation, and that, too, in a case where 
there is really a virulent bubo. Further still, we are not even 
certain of obtaining virus in extracting matter from a" gland, the 
suppuration of which has been specific, for we may be too late, 
that is, at the time of reparation, when the pus secreted is no 
longer virulent. Inoculation, therefore, does not remove the diffi- 
culties ; it rather creates more. Clinical experience must furnish 
us with the principal information required to form a diagnosis ; it 
is the combination of certain constitutional and local symptoms, 
together with the antecedent circumstances, that can lead to prac- 
tical truth. In the last analysis, what tumor may be confounded 
with bubo ? The scrofulous. Now, the scrofulous, or, if it please, 
the strumous tumor, occurs in subjects who have had certain ante- 
cedents from infancy, from puberty, whose signification is known, 
and their systems have had certain marks which cannot deceive 
those who have studied the temperaments. Again, it is rare that 
there is the tumor in the groin only ; but we find them in other 
regions, as the neck, for example ; and in the groin, even, we find 
an enlargement of more than one of the deep-seated glands, as well 
as in the pelvis ; in fact, it is rare that the strumous bubo does not 
involve the supra- aponeurotic glands. In its development and 
progress, it resembles other strumous tumors. The engorge- 
ment begins in one or two glands, it forms slowly, and is 
attended with little or no pain. This indolent character remains 
for a long time, and the skin continues sound, not changing 
even its color. But under the influence of a physical cause, 



244 VIDAL ON VENEREAL DISEASES. 

or some excitement of the system, sometimes without any appre- 
ciable cause, the inflammation attacks the glands already engorged ; 
the, pain is now severe ; there is an erysipelatous redness of the 
skin, and thickening of the cellular tissue. These phenomena may 
be but temporary, and the tumor may thus be many times re- 
newed. It finally softens, and forms not one but several foci con- 
nected with the lobes of the different glands ; and as the deep- 
seated glands of the groin and pelvis may be simultaneously 
affected with the superficial, the suppuration may be very pro- 
found. 

In describing the suppurating inflammatory bubo, it must have 
been remarked that it was attended by a different train of phe- 
nomena. The tumor, in this variety of bubo, is of limited size, 
its progress is acute, its suppuration rapid, and generally it forms 
but one focus of matter. After the bubo is opened, it does not 
present that successive degradation of strumous pus, which is at 
first thick and well assimilated, then demi-serous with flakes, and 
which always becomes more liquid and of a redder color. When 
the bubo is once opened, be it strumous or venereal, it becomes 
an ulcer which in both cases may possess analogous characters, 
but between which differences exist, which I will indicate. Both 
ulcers may have a fungous base, of a dull gray color. But in the 
ulcer from a venereal bubo, a false membrane covers the base, 
and we may remove it by gentle rubbing ; then the color of the 
wound is of a more or less lively red. In the strumous bubo, the 
base of the ulcer, on the contrary, is formed by the gland itself, 
which is more or less fungous, and has the gray color, which can- 
not be made even momentarily to disappear. These glands more 
or less hypertrophied, sometimes rise above the level of the skin, 
which tends greatly to retard the healing of the ulcer. Further, 
the skin around the ulceration is thin, not red, but more or -less 
livid. When the ulcer is venereal, there is always more or less 
inflammatory turgescence, and the cellular tissue of the base, that 
which lies under the skin, is more or less rigid ; the gland does 
not so soon become exposed. Yenereal ulceration, besides, makes 
too rapid progress in the commencement to be afterwards suddenly 
arrested, and then to march speedily towards reparation. The 
contrary is true of strumous ulceration, which is slowly established, 
which progresses slowly, and heals still more slowly. 

But, unfortunately, both the strumous and the venereal dia- 
thesis may be so blended, that the bubo having the characters of 
both, may render the diagnosis very difficult. Hunter very 
justly remarked : "There are buboes which are nothing else than 
a gland endowed with a scrofulous disposition, in which the mor- 
bid action has been provoked by venereal irritation."* Occasion- 
ally we meet with a bubo which has been preceded by a chancre 
on the penis, or a urethral blennorrhagia has inflamed, suppurated, 
and opened in the same manner as a syphilitic bubo ; the stru- 
mous engorgement then manifests itself, and it assumes the char- 

* On Bubo, chap. iy. 



bubo. 245 

acters which I have described. Here the venereal accident, on the 
part of the penis, has excited the scrofulous disposition of the 
glands of the groin, and has given to the strumous adenitis an 
active character, which did not belong to it before the venereal 
irritation was superadded. There are cases where the bubo is 
truly venereal ; its onset, its progress, the ulceration which in 
vades the skin, all prove it; we then have evidently what is called 
a glandular chancre. But the scrofulous principle which, so to 
speak, had remained in its essence, began to act, and then it could 
produce two effects : it might complicate the venereal ulcer, cause 
it to be transformed into a phagedenic ulcer, which is a very 
grave affair; or, the venereal symptoms disappearing, scrofula 
gained the ascendency, the ulcer and the tumor assumed the 
characters which I have just assigned to the strumous ulcer of 
bubo.* 

From what I have stated, it will be seen that the difficulties in 
forming a diagnosis are real ; and, in the present state of the 
science, it is not possible entirely to remove them. But the knowl- 
edge of these difficulties will cause the young practitioner to be 
at least guarded in announcing his opinion, to be prudent in his 
treatment, and to be discreet in his remarks before interested per- 
sons or in courts of justice. Thus, what we should here avoid is 
being too absolute, that is, when we come to the treatment, we 
should not persist in the administration of mercury when several 
courses of this mineral have not had a happy result. We should 
then remember the possibility of a strumous complication, and act 
-accordingly. 

[In the Compendium de Chirurgie Pratique, of Berard and M. 
Denonvilliers, vol. 1st, p. 43, a case is reported which occurred at 
the Hopital du Midi, in 1812, and in which one of the internes 
opened an aneurismal tumor, supposing that it was a bubo! — 
Gk C. B.] 

Prognosis. — This may be inferred from what I have stated in 
speaking of the different varieties of buboes and their complica- 
tions. The most terrible of all is the strumous complication which 
may convert the ulcer of a bubo into a phagadenic chancre. We 
then observe those extensive denudations of the groin, which 
invade even a part of the abdomen, and exhaust the unfortunate 
patient by his sufferings and the abundance of the suppuration. 

[Mr. South states, in the second volume of his edition of Chel- 
ius (p. 90), that he has known a sloughing bubo destroy life, by 
ulcerating the femoral artery. — Gr. C. B.] 

Treatment — Nicholas Massa recommended that buboes should be 
allowed to suppurate ; he regarded them as a kind of emunctory 
destined to rid the system of the poison and to render the patient 
less liable to consecutive accidents, to the confirmed pox. This 
opinion, which others would call error, has always found sup- 
porters. Even at the present day we find in the work of M. 
Baumes, that subjects in whom buboes have suppurated, are less 

* Vide an article by M. Gabalda, in the Bull TJierapeut, Jan. and March, 1846. 



246 VIDAL 01S T VENEREAL DISEASES. 

frequently troubled with consecutive accidents. To this it has 
been replied, that suppurating buboes coincide with the common 
chancre which does not generally produce the pox. I have already- 
shown that this assertion is not true. 

[It is to be regretted that upon this, as on so many other doc- 
trinal points, the views of as weighty an authority as M. Eicord, 
should be so contradictory. For example, in his Treatise (Am. ed., 
p. 76), he remarks : " Experience having shown that buboes which 
do not inoculate are never followed by secondary accidents." 
Now in his Letters, (xxvii., p. 199,) he asserts that: " Every bubo 
which suppurates specifically, that is, which furnishes inoculable 
pus, is never followed by constitutional infection !" Which of 
these doctrines are we to believe? One thing we know to be 
true, viz., that constitutional infection sometimes occurs after a sup- 
purating bubo, whether such suppuration be specific or non- 
specific. — Gr. C. B.] 

For my own part, I will not here discuss the question, whether 
it is better to promote or to prevent suppuration in a bubo ; for I 
believe it to be almost impossible by any of the ordinary means of 
treatment to obtain either of the results. The bubo that should 
suppurate, will suppurate, no matter what we do, and the bubo 
which should disappear by resolution will thus disappear in spite 
of the application of the ordinary suppuratives, except they be too 
violently used. Does it follow that I would dispense with the 
treatment of buboes ? No! I believe, on the contrary, that we 
have a preventive treatment ; a palliative treatment, and a surgical 
treatment to employ. 

1st. Preventive Treatment. — Among subjects affected with chancre, 
there are those who greatly neglect hygiene, who do not observe 
repose, who labor, and who abandon themselves to pleasure ; these 
are the persons in whom we most frequently meet with buboes. 
As to the frequency of this accident, there is a marked difference 
between the working population who frequent our hospitals, and 
the patients which we treat in private practice. This fact, to 
which I alluded in speaking of the etiology of buboes, should in- 
duce the practitioner to recommend hygienic measures to the pa- 
tient, and to insist that he avoid fatigue, and observe the most 
absolute repose. A well directed local treatment of chancre may 
prevent the formation of a bubo. M. Ricord advises that we 
should not irritate a chancre. I would remark that it is a practice 
with him to cauterize them, and to dress them with aromatic 
wine. 

2nd. Abortive Method. — This consists in cold applications, the local 
abstraction of blood, and the use of compression. A kind of cau- 
terization with a solution of fifteen grains of the bichloride of mer- 
cury to an ounce of water, has also been employed. The skin is 
first removed by means of a blister. This painful and uncertain 
method is now abandoned even by those who recommended it. I 
shall again allude to this treatment, which is better adapted to the 
suppurating bubo. 

The glans have been incised subcutaneously. I know not the 






bubo. 247 

results thus obtained. Some have gone so far as to propose the 
subcutaneous division of the lymphatic vessels which pass from 
the chancre of the glands. To this I would reply : when the 
glands are already infected, what advantage can possibly follow 
the section of the one or more of the lymphatic vessels ? If infec- 
tion had not taken place, then the incision might be preventive. 
But is this advisable for a disease which may not be developed ? 
Again, supposing that chancre is certainly followed by bubo, can 
we predict what gland will be affected, or on which side it will be ? 
Is it possible in all cases to strike upon the lymphatics of the 
glands which will be affected ? Is it exclusively the office of the 
lymphatics to carry the virus to the glands ? 

Further, to appreciate the value of tbe abortive method in 
general, we must ascertain the facts relative to the dispersion of 
buboes. Does this often occur? Clinical observation, on the 
contrary, teaches that bubo once formed, in other words adenitis 
once established with more or less inflammation of the surround- 
ing tissues, is very seldom observed to disappear in the rapid man- 
ner that resolution supposes. I assert that it is very rare ; I do 
not maintain that it is impossible, for I have seen some exception- 
able instances of the disappearance of the suppurating buboes, but 
they were immediately followed by a phlegmonous inflammation 
of the cellular tissue of the scrotum, an inflammation which is 
known to be connected with mortification of the parts. In these 
cases it was a kind of metastasis. 

The proper treatment has reference to three varieties of buboes. 

1st, the inflammatory bubo : 2d, the suppurating bubo : 3d, the 
chronic indolent bubo. 

3d. Antiplihgistics. — In the treatment of inflammatory bubo, anti- 
phlogistics are plainly indicated. In some cases they may produce 
resolution, and frequently limit the extent of the inflammation, as 
well as the purulent cavity, if the inflammation become really 
phlegmonous, and terminate in abscess, if, in fine, suppurating 
bubo succeeds to the inflammatory bubo. 

As in every case of adenitis, when the patient is young and 
vigorous, when the inflammation has decidedly an acute character, 
when the premonitory symptoms and the reaction are marked by 
fever of an inflammatory grade, it is well to begin with a general 
blood-letting, and afterwards resort to the application of leeches. 
In the majority of cases, we rely on the local abstraction of blood, 
which is repeated and proportioned to the volume of the tumor, its 
tension, and the pain of which it is the seat. We may apply from 
ten to forty leeches. The largest number should be applied 
at first ; and when the leeching is repeated, a smaller number may 
be used. 

The mercurial ointment, not as ordinarily applied in small quan- 
tities, but in thick layers, as in the treatment of peritonitis, may 
produce a sedative and really antiphlogistic effect. But if we do 
not perceive a marked result on the first or second day, and if we 
find it necessary to continue the application, we are in danger of 
producing an annoying salivation. I therefore employ mercury 



248 VIDAL ON VENEREAL DISEASES. 

only as a topical application, and do not believe that we should 
aim to affect the system by these frictions. I cannot believe chat 
when we have to treat genuine buboes, we can cnre them in four or 
five days by means of mercurial frictions, as Swedianr maintained. 

Our topical applications should be confined to rice or linseed 
cataplasms, or to those of semoule, and of bread. When there is 
much pain they may be moistened with laudanum ; in other cases, 
we may use Goulard's extract. Rest, a diet more or less rigid, 
soothing drinks, gentle laxatives, complete the treatment of in- 
flammatory bubo, of adenitis. Too often, notwithstanding these 
means, and especially when they have not been employed, the 
tumor retains its volume ; it becomes more and more tense, crepi- 
tating and of a deep red color. The fever continues, the redness in- 
creases, and soon a constant throbbing pain is felt. The patient 
is troubled with sweats, and the formation of matter can now no 
longer be questioned. When fluctuation is felt, should we open 
the tumor or leave it to nature ? 

4th. Spontaneous opening of Bubo. — In all ages some practitioners 
have preferred to leave to nature the opening of the abscess and 
the evacuation of the pus. Swediaur, who especially taught this 
practice, maintained, that abscesses thus left to open spontaneously 
were more rapidly consolidated, and when cured left less deformity 
behind. Swediaur, however, is less absolute than is stated in 
books ; he admits that there are cases in which the surgeon should 
dilate the natural opening, and in which he should even open the 
bubo with the knife. However it may be, Swediaur stands at the 
head of the advocates for a spontaneous opening, and he has ad 
duced the strongest arguments in favor of the expectant method 
of treating buboes. As to the speedy consolidation, that is, the 
cure, we may reply, that in allowing the pus to remain we favor 
the exposure of the gland, and its suppuration in cases where the 
surrounding cellular tissue alone is inflamed, by permitting the 
cavity to increase, and the abscess, which is never simple, to be- 
come still more complicated, and of course to retard the cure. 
As to the deformity I may be still more explicit ; I may assert 
and can prove that there is a great difference between the natural 
and the surgical proceeding, such as I practice, be it well under- 
stood. Indeed, in the majority of cases, spontaneous opening 
does not occur until the skin has been detached, and become very 
thin ; this perforation besides is but a form of mortification, and 
around this first loss of substance, there is more or less skin ready 
to mortify, and which most frequently does mortify ; thence an 
enlargement of the first breach or rather other openings form. In 
the most favorable cases this skin requires a long time to become 
again adherent. If there be but one opening, it enlarges unequal- 
ly ; its thin, sharp borders, sink down towards the bottom of the 
abscess Should there be several openings, they often become 
converted into one large unequal breach, which is never completely 
covered by the surrounding skin, and an modular tissue appears, 
an irregular cicatrix, depressed, stellated, and evidently deformed ; 
if the openings do not become blended into one, the fistula to 



bubo. 249 

which they give rise are exceedingly difficult of cure. These re- 
sults are seen principally among patients who have received no 
care, who have worked and walked, and observed nothing like 
repose. The movements have then affected the diseased parts, 
and this, together with the chafing, has promoted the separation 
of the skin. It will presently be seen that the openings which I 
substitute for those which occur spontaneously, are not attended 
with such inconveniences, nor do they leave behind deformities. 
But, before describing my method, I must rapidly expose and 
'judge those which have preceded it, and which are still preferred 
by other practitioners. 

5th. Blistered surface dressed with bichloride of mercury — a 
method of which a wrong estimate has been formed, and which, 
has been badly applied, especially at Paris, is that of M. Malapert. 
This physician proposed to open thoroughly the suppurating bubo 
by means of a concentrated solution of the bichloride of mercury ; 
but he proposes to act particularly upon the cavity, so as to 
modify it specifically ; he supposes, also, that he thus acts on the 
whole system. M. Malapert, therefore, proposes to fulfil a double 
indication, and his treatment is intended to produce both a local 
and general effect. M. Eeynaud, of Toulon, who has most fre- 
quently and perfectly employed the method of M. Malapert, does 
not apply it for the purpose of opening and evacuating the bubo 
to more advantage than the other methods. It is only in this 
point of view that I judge it, for I believe that medicines to coun- 
teract a diathesis should be administered internally. The follow- 
ing is the proceeding : 

When suppuration is first detected in the bubo, a blister of the 
size of from a fifty centime to a franc piece, according to the vol- 
ume of the tumor, is to be applied to the point of fluctuation. The 
vesicle is opened, and on the denuded dermis is placed a pledget 
soaked in a solution of the bi-chloride of mercury, of the strength 
of fifteen grains to the ounce of liquid. Two hours afterwards 
an eschar is already formed ; should it not be completely formed, 
the application is to be renewed, and then an emollient cataplasm. 
Thirty-six or forty-eight hours after the formation of the eschar, 
and as soon as it is detached, a purulent liquid exudes from the 
fissures. The discharge is more abundant in proportion as the 
eschar becomes detached at several points ; after it has fallen off, 
the cavity is sometimes entirely emptied. During the discharge 
of the liquid, the walls of the cavity contract, and the cavity itself 
is soon effaced. 

It is obvious that a cauterization of this kind can be rationally 
employed only in the case of a superficial and very limited sup- 
puration, and even when the abscess is subcutaneous, we occa- 
sionally find it necessary to return to a second application of the 
caustic pledgets, which renews the pain. In employing the pro- 
ceeding of M. Malapert, we must therefore wait until the suppura- 
tion has been for awhile established, for there is then more or less 
detachment, more or less denudation of the skin ; it is likewise not 
Uncommon to see the eschar very rapidly separated, and the open- 



250 YIDAL ON VENEREAL DISEASES. 

ing winch it leaves becomes enlarged by the mortification of the 
integuments, which were at first only attenuated. In fine, this 
method is liable to the inconveniences which follow the spontaneous 
opening of the tumor. If the abscess be deep seated, and the pus 
be situated within the gland, the difficulty, and even impossibility 
of reaching it by a very superficial cauterization, can be appre- 
ciated. Add to this, if the pus be contained in more than one 
cyst, a part only can be evacuated, thence the necessity of renew- 
ing the blister and the pledget ; in other words, to inflict double 
pain to finish the matter, if we finish it at all. 

It will be seen that the supposed advantages of this method 
are : 1st, to empty the abscess gradually so as to permit the cavity 
to contract upon itself; 2d, to stimulate the interior of the cavity, 
and thereby promote the adhesion of its walls. The first I believe 
to be a real advantage ; but I think that it can be more easily, 
more surely, and less painfully obtained by the method of punc- 
turing which I will describe. As to the second advantage, I will 
say that the interior of the cavity is always sufficiently excited to 
produce an adhesion of its walls ; when it does not take place, it 
should be attributed to every other cause than inertia. 

6th. Instead of perforating with the caustic solution, M. Eeynaud 
often employs small sized cauteries, which are heated to a white 
heat, and with which numerous punctures are made. This is not 
a new method ; for a long time it has formed a part of the thera- 
peutics of abscesses in general, especially of cold abscesses. Its 
object is to open the purulent cavity, and, at the same time, so to 
modify its walls as to promote their approximation and adhesion. 
This method is more rapid than that by blisters ; it is painful, but 
the pain is not repeated as in the method by the caustic solution. 
Still, even by these little cauteries, a loss of substance is produced, 
by which a breach is left, which is increased by the sloughing of 
the surrounding skin. Thus we do not avoid the deformity or 
deformities which attend the cure. Moreover, M. Eeynaud, of 
Toulon, who has extolled and much employed this method, frankly 
acknowledges, that after these trifling cauterizations, this separation 
and destruction of the skin, he has observed solutions of continu- 
ity sometimes complicated with hospital gangrene. Although it 
may be more easy to manage these little reeds than the solution 
of the bi-chloride of mercury, we can never accomplish with them 
what can be done with the point of a bistoury or a lancet ; thus, 
with the actual cautery we cannot penetrate deeply, and still less 
obliquely. 

7th. Potash. — Vienna Paste. — Other caustics, potash alone, and the 
Vienna Paste, are employed for the purpose of freely opening the 
cavity, of modifying it deeply, and for destroying a portion of the 
skin over the glands that has been a long time affected. It is par- 
ticularly in .cases of indolent buboes with a strumous complica- 
tion, that these caustics have been used. Long and deep sinuses 
form, which fill up with difficulty, and the traces which it leaves 
behind are very apparent. Now a mark of this kind, in such a 
region, is a stigma, which may become of serious importance. It 



BUBO. 251 

must not be supposed that the elegant man, or the coquettish 
female, is the only person who has a dread of such traces, of such 
souvenirs ; among the masses, and in classes apparently the most 
indifferent to such matters, we occasionally find individuals who 
are sadly mortified when compelled to carry a deformity claiming 
such an origin. 

8th. Incisions. — Excisions. — In all ages, the knife has been substi- 
tuted for the cautery ; incisions, more or less extensive, have been 
performed, and portions of skin so altered as to retard cicatriza- 
tion, have been excised. These extensive incisions, with or with- 
out the removal of portions, have for the most part the inconve- 
niences attached to the cauterizations which I have described. 
But the knife is more easily managed than the caustic, and I 
prefer to extirpate a detached portion of skin, of little vitality, or 
a gland which presents an obstacle to the healing of the parts, 
than to act upon them with the Vienna paste. Besides, as with 
the knife we may give to the wound a certain regularity, we may 
expect a cicatrix less irregular, less deformed, than after cau- 
terization. 

9th. Simple and multiplied punctures. — Proceeding of the Author. — 
As may well be supposed, I do not here raise the question of pri- 
ority for the purpose of deciding it in my favor. I write for the 
practitioner, who, perhaps, cares but little for the hand that offers 
him a therapeutic measure. What he chiefly wishes to know, is 
its efficacy, and how it is to be employed. I will only remark, 
therefore, that in the first edition of my work on surgery, I recom- 
mended small incisions, punctures with the lancet, and I claim 
only to furnish arguments in favor of this practice, and to teach it 
more in detail than others. I pass, then, at once to the modus 
faciendi, to the proceeding that constitutes the basis of my 
practice. 

We commence, if possible, by shaving the tumor. As it is sel- 
dom that a bubo has not had at least one plaster applied, we 
should remove its effects. The instrument required for the punc- 
ture is a straight, sharp bistoury, the blade of which is not larger 
than a penknife ; or we may use a lancet. If the suppuration be 
not extensive, and the abscess recent, we make but one puncture, 
or one incision, of a centimetre in extent, over the fluctuating 
point. We sometimes find that but a single gland has suppurated, 
and it is then emptied of the pus which it contains ; the other and 
adjacent glands are only engorged ; should they afterwards sup- 
purate, they should be treated like the first. We may thus open, 
and successively puncture, as many as four glands. It is especially 
among scrofulous subjects that this peculiarity presents, and which 
must be treated by successive punctures. When suppuration 
exists within the gland, it is more difficult to be detected, because 
more deeply seated ; we must then extend our incision to a greater 
depth in order to reach the cavity. This is another argument in 
favor of the knife over the caustic, as with the knife we may 
reach any desirable point, and the instrument may assist us in our 
explorations. 



252 VIDAL ON VENEREAL DISEASES. 

Should the purulent collection be of greater extent and more 
superficial, and the skin more or less detached, we must make 
several punctures at the same sitting. But instead of making them 
at the most fluctuating point, we must avoid the centre of the 
tumor, and regions where the skin is thin ; instead of being direct, 
thej should then be sub-cutaneous, so as to reach the pus by a 
circuitous route ; it is, therefore, towards the circumference of the 
tumor that we should enter the knife, the point of which is di- 
rected towards the centre of the cavity. In this manner, the skin 
is divided where it is inherent, intact, and in possession of all its 
vitality. When punctured where it is thin, denuded, and pos- 
sessed of but little vitality, the opening is likely to become en- 
larged from mortification, which is hastened by the puncture, an 
enlargement of the openings is thus produced, the result of which 
is a general communication. A large breach of continuity is now 
formed, to which the air has access, placing the bubo in the unfa- 
vorable circumstances of those that have been freely opened by 
the caustic or the knife. In making the punctures at the points 
indicated, if the tumor be not compressed (it should not be com- 
pressed for a few days after the operation), it is gradually emptied, 
and the cavity is, in a measure, filled by the contraction of its 
walls. The cure is then much more rapid, and it leaves no un- 
pleasant traces behind. The cicatrices of these punctures, indeed, 
resemble those of leech bites ; and, like the latter, they finally 
completely disappear. The punctures thus made, obliquely and 
towards the circumference of the tumor, excavate passages of 
which the walls sometimes contract too speedily on themselves, 
whereby they become obliterated before the pus is completely 
evacuated. But, as several openings are made, and as it is rare 
that all are obliterated by compressing the tumor slightly once a 
day, the cavity may be discharged through the openings that re- 
main. It will be remarked, that I here advise compression which 
I so recently proscribed ; but it will doubtless be remembered, 
that it was for the few days following the operation, when the pus 
is still abundant, and the openings perfectly free, that I recom- 
mended to abstain from compression. Sometimes all the openings 
have a great tendency to close speedily. I formerly tried to keep 
them open by means of a tent of charpie ; I now prefer to let them 
close, after which, if any pus remain, I make one or two more 
punctures. Sometimes what remains becomes absorbed, and there 
is, of course, no necessity for repeating the punctures. 

The advantages of this method are obvious ; 1. It is of easy and 
rapid application ; 2. It is less painful than the others ; 3. It pro- 
duces more speedy cures; 4. It leaves no deformity. I know 
what objections may be urged against it. It may be said that it 
is really advantageous only in the case of sympathetic buboes, or 
those which result from the extension of the inflammation, or from 
irritation of the genital organs, in other words, when the abscess 
is of a simple character ; it may be urged that in the case of really 
syphilitic buboes it has not the same advantages, as the little open- 
ings will become inoculated and transformed into so many chancres, 



BUBO. 253 

which, may become united and confounded into one, constituting 
one vast ulcerated breach of continuity. In the first place, the 
proof of the inoculation of these little punctures is very difficult to 
be found ; and if I should reckon syphilitic suppurating buboes 
by the number of those which having been thus opened, were 
inoculated, I should find that there were but a small number of 
buboes in my service which had that nature. I have not witnessed 
this inoculation more than three times in a year. But I would 
observe, that when a bubo is established I adopt general treatment. 
Others will say that this goes to show that many buboes, even 
syphilitic, produce a pus that is not inoculable. They may explain 
the fact as they please. It may also be said that I do not often 
penetrate the substance of the gland, and that I reach the surround- 
ing cellular tissue only, which is possible. What I maintain, for 
I treat the question in its practical bearings only, is, that in adopt- 
ing my proceeding buboes are sooner cured and without deformity, 
which cannot be claimed for the other methods. I have stated 
that I have rarely observed the inoculation of the trifling wounds 
thus made ; I will add, that I have seen one or two instances in 
which some of the wounds became invaded, the others remaining 
unaffected. But if all the wounds did become inoculated, thus 
forming one vast chancre, it would then possess the inconveniences 
of the other methods, of the free incisions, and cauterizations which 
I know are exposed to the action of virulent pus. 

The students who have followed my visits, and who have been 
attached to my service, have been able to observe and compare the 
results obtained by this method with those that have followed the 
others, and they can appreciate its value. M. Caillant, one of my 
internes, has collected a very considerable number of cases which 
deserve publication. 

10th. Puncture with Injections of Iodine. — M. J. Roux, of Toulon, 
and Marchal (de Calvi) have proposed simultaneously to inject the 
purulent cavity with the combination of iodine, employed in the 
radical treatment of hydrocele. In the first place, we empty the 
abscess by a puncture, and with a small syringe, introduce into 
the cavity the tincture of iodine diluted with equal parts of water. 
This mixture then takes the place of the pus, comes in contact 
with the walls of the cavity, stimulates and so modifies them as to 
promote the adhesions which should obliterate the cavity. The 
iodine acts also as a resolvent on the engorged glands, which is of 
great advantage in cases of strumous complication. 

11th. Compression. — Compression has been proposed both as an 
abortive means, and consequently to be employed at the com- 
mencement of buboes, and as a resolvent means, to be used in the 
case of chronic indolent buboes. In speaking of the abortive treat- 
ment, I have already stated that it is impotent, and among the 
abortive means I include compression. But, if it be well supported 
and continued for a long time, if the surgeon knows how to resume 
its use when the tumor has a tendency to be reproduced, very good 
effects may be derived from compression in the case of strumous 
buboes, especially if, at the same time, we administer internally 



254 VIDAL ON VENEREAL DISEASES. 

medicines adapted to the nature of the case, and to the diathesis 
under the influence of which these tumors are developed. The 
preparations of iodine are here suitable, as are the mercurial, when 
the indolent bubo is a consecutive accident, or one of the effects of 
indurated chancre. 

Rest is an excellent auxiliary to compression ; the patient should 
observe it as much as possible. We may compress with the spica 
bandage, under which may be placed graduated compresses ; or 
we may use a hernial truss, the pad of which should be adapted to 
the volume and form of the tumor. At the Eopital du Midi, a 
little apparatus has been successfully used which was invented by 
a former externe. It is a little oval pad covered with leather. It 
is fixed by a strap which, being attached to the extremity of the 
pad, at the internal part of the inguino-crural fold, passes around 
the thigh, reaching on its external surface, an iron loop attached to 
the external surface of the pad passes through it, and having been 
reversed is passed around the pelvis, gaining the opposite side of 
the body, then arriving at the anterior wall of the abdomen it 
descends obliquely towards the compressive pad, and passes 
through a buckle on its internal side, by the aid of which the 
apparatus is tightened at pleasure. An apparatus is required for 
each side.* 

[Another method of pressure has been recently recommended 
by Dr. J. H. Clairborne, in the Stethoscope and Virginia Medical 
Gazette. He states that in his hands it has proved incomparably 
superior to any other discutient. It consists in the application of 
Collodion, which, when applied too thickly, he has known to con- 
tract so tightly as to split the ejDidermis, in fissures around the 
borders. *He recommends its application in thin layers, allowing 
one layer to dry before another is made. The above account we 
gather from the Nashville Journal of Medicine and Surgery for 
June 1853, p. 351.— G. C. B.] 

12th. Various Combined Methods. — It is rare that in the treatment 
of bubo, especially its chronic form, different means are not resorted 
to, and that these means are not alternated, and in a certain manner 
combined. Thus, in the treatment of bubo, which M. Eicord 
regards as the necessary accompaniment of the indurated chancre, 
local mercurial frictions, the plaster de Vigo, and general treatment, 
should go hand in hand. According to the same practitioner, a 
combination very often efficacious in the treatment of non-specific 
indolent bubo consists in the employment of blisters, mercurial 
ointment and cataplasms, as long as we obtain an amelioration; 
but if it remain in statu quo, the blister is allowed to dry in order 
that we may resort to compression, which in turn is continued whilst 
it produces a diminution, and is abandoned if it produce no effect for 
the blister ; and thus in succession these means are employed until a 
complete cure is obtained, f I have been desirous of noticing this 
combined treatment as it was proposed by M. Eicord himself. The 

* Ricord, Traite pratique des maladies veneriennes, p. 588. 
f Ricord, Traite, &c, p. 588. 



VEGETATIONS. 255 

obscurity of the formula will perhaps be noted at once as well as 
the difficulty of its execution. 

In conclusion, I still advise the general treatment adapted to 
the nature of the tumor ; this is the best of all resolvants. 



CHAPTER YII 

VEGETATIONS. 



These are parasitic growths appearing on different parts of the 
integuments, and which resemble certain vegetables. 

Situation. — In the male, they are observed most frequently on 
the mucous membrane, covering the glans and lining the prepuce ; 
in the female, at the entrance of the vagina ; we may find them, 
and not unfrequently, in the vagina itself ; I have seen them on 
the neck of the uterus and surrounding the nipple. In both sexes 
they occur in the vicinity of the anus, in the urethra, especially at 
the entrance of the canal ; they are met with also in the genito- 
crural fold, at the umbilicus, on the lips, mouth, and base of the 
tongue. I once saw them on the mucous palpebral lining, in a 
subject that had suffered from blennorrhagic ophthalmia. 

Varieties. — All seem to penetrate the dermis, and to be more or 
less expanded. Their mode of insertion and expansion, their 
pedicle, and color, present differences which have caused them to 
be compared with warts, cauliflowers, leeks, strawberries, and 
raspberries. Some are sessile, having no pedicle— they are small, 
and their surface is fissured : these are the paler vegetations called 
warts. When there is a kind of stem, of one or more lines in 
length, with a swelling of a deeper color, in the shape of a fur- 
rowed head, it is called the leek. If the stem give rise to many 
branches, which shoot off so as to form several united bouquets, 
then we have the cauliflower excrescence. There are other vegeta- 
tions with protuberances strongly marked, of which the shoots are 
less distinct, the prominences less decided ; they are quite red ; 
they have been denominated strawberry excrescences or raspberry 
excrescences, according to the depth of their colors. ( Vid. plate 4, 
fig. 1.) The form of the vegetations occasionally depends upon 
the seat which they occupy : thus, in a prepuce somewhat narrow, 
they are pressed between this envelope and the glans, and assume 
more or less the form of the crest of the cock (fig. 1, plate 4) ; the 
same sometimes occurs when they are seated between the nates. 

Structure. — All of these vegetations are more or less vascular, 
and especially the last-named varieties. By prolonged maceration 
all that part above the level of the skin becomes discolored and 
reduced to a whitish pulp, without any regular organization, and 
resembling coagulated albumen ; it is easily removed by scraping. 
Thrown on hot coals, this matter desiccates, hardens, turns yellow, 
and emits an odor like that of burning horn, or other productions 



256 YIDAL ON VENEREAL DISEASES. 

of the epidermis. In fact, M. Sibert has discovered, by means of 
the microscope, that these vegetations contain only cells of the 
epidermis and a vascular element.* The point at which they are 
inserted into the integuments appears to be somewhat thicker than 
in the normal state ; it is redder, and traversed by numerous 
vessels, some of which penetrate the vegetation. The dermis seems 
also to be a little thickened. The epidermis is not perforated, but 
rises with and covers the vegetation. Sometimes the vegetation is 
but a disease of the mucous or cutaneous follicle, preceded by a 
little black spot on the skin ; the secretion of the follicle becomes 
more and more concrete, the follicle itself suffers a kind of extro- 
version, and presents a granulated base, on which are seated rough 
projections in the form of a leek. 

Symptoms. — Frequently the appearance of the vegetations is not 
preceded by any modification of sensibility. The patient some- 
times experiences a slight pruritus at the point where the vegeta- 
tion is about to shoot forth ; this pruritis increases, and there is a 
sensation of pain until the production appears. Once developed, 
it is often indolent or only painful when chafed. At other times, 
it is painful even without the application of any irritating cause. 
There are cases in which it may be said that there is no pain in 
the vegetation, but the latter may be the exciting cause of it : for 
example, when numerous and voluminous vegetations are enclosed 
within a narrow prepuce, they are a source of irritation, and in- 
flame the lining membrane of the glans, as well as of its envelope ; 
they distend, and stretch the latter so as to produce severe pains, 
which cease on the division of the prepuce to a sufficient extent to 
expose the morbid mass. In these cases, especially after they 
become exposed to the air, they assume the color of the raspberry. 
A discharge is now secreted of a very disagreeable odor. The 
vegetations themselves may be the seat of a congestion bordering on 
inflammation. Sometimes they slough, and this is one method of 
cure. But as this mortification is but partial, the cure is not com- 
plete ; roots always remain, from which the vegetations may be 
reproduced. 

Complications. — Accidents. — The venereal accidents which I have 
regarded as the starting point, the cause of the vegetations, may 
also exist as complications ; thus, chancres more or less advanced, 
a blennorrhagic inflammation, mucous tubercles, according to their 
seat and volume. Vegetations may themselves give rise-, to acci- 
dents, and interfere with important functions ; as of the urethra, 
the vagina and the penis. 

The possibility of a cancerous transformation of the vegetation is 
generally admitted. I am inclined to believe that those which have 
been regarded as cancerous transformations, were primarily of that 
character ; in other words, that the venereal vegetation did not exist. 

Diagnosis. — This is easy when observed on their first appear- 
ance, and when their development has been watched. But, under 
the opposite circumstance, it is more difficult. The vegetations 



Physiologie pathologique, t. i., p. 23. 



ons 



VEGETATIONS. 257 

on the glans and prepuce furnish the most frequent examples of 
difficult diagnosis. Thus a vegetation incarcerated within a narrow- 
prepuce in a state of phimosis, may be very difficult of detection. 
It may be regarded as an indurated chancre, a calcareous concre- 
tion, or a deposit of sebaceous matter, according to its volume, 
consistence, and insensibility. At a clinical trial of the concours of 
the central bureau, a patient was submitted for examination who 
had a congenital phimosis. This patient, already advanced in 
years, for a long time had had a tumor within the prepuce. By 
pressing through the skin, this tumor was insensible and very 
hard ; the introduction of a probe produced no pain, and gave exit 
to not the slightest particle of blood. The majority of the jurors 
remained doubtful of the nature of the tumor, and in this uncer- 
tainty the candidate participated. An incision of the prepuce, 
afterwards made, revealed the existence of a very old vegetation 
which possessed but little vascularity. Lately there was in my 
service a young man who had within his prepuce a very decided 
induration, clearly representing a vegetation ; the appearance of 
an eruption (roseola) disclosed the fact of the existence of a chancre, 
with a very indurated base. 

But the cases most obscure, and those in which the diagnosis is 
really of great importance, are those of old degenerated vegetations, 
which invade and cover the glans, and which present a cancerous 
aspect. The morbid masses, in these cases, exhibit softening at 
certain points, and at others indurations ; some become mortified ; 
hence, they have a grayish aspect, an unequal consistence, and are 
the seat of a sanious fetid discharge. If to this condition, we 
add the emaciation of the subject, the pallid countenance, the ef- 
fects of a prolonged suppuration, and it must be admitted, some- 
times of treatment, it will be perceived how easily these vegeta- 
tions may be confounded with cancer of the penis, and we need 
not be astonished that such errors have been committed ; the mis- 
take may be so complete, as to induce the practitioner to ampu- 
tate the penis. This error, sometimes, is not removed even after 
amputation and dissection of the parts. The cause of this is the 
atrophy of the glans caused by the compression of the vegetating 
mass ; this is occasionally so great that the glans seems to have 
disappeared. But when the diagnosis has been clearly established, 
when the vegetations alone have been removed, the glans gradu- 
ally recovers its form, and almost its ordinary volume. The diag- 
nosis, I repeat, is here very obscure, and Ave are deceived in a 
double sense Indeed, in certain cases, true vegetations have been 
mistaken for cancer, and vice versa. The first mistake was com- 
mitted in my service, by one of my former internes, who has writ- 
ten on venereal diseases, and the other by surgeons who quickly 
decided to sacrifice the organ. Besides their microscopic charac- 
ters, vegetations are to be distinguished from cancer, after their 
removal, by their great vascularity, which causes them in a short 
time after separation to diminish one half in size. During life, the 
diagnosis is much more difficult, especially if the early develop- 
ment has not been seen. If observed at the onset, it will be 

17 



258 YIDAL ON VENEREAL DISEASES. 

found that cancer does not at first appear as a pimple, but as an 
ulcer ; and it is surrounded by more or less induration. Vegetations 
seldom exist alone ; they first appear by several shoots, and the 
surrounding tissues are soft, except when they spring up on the 
induration around a chancre. Age, also, should be taken into 
consideration. Thus when the subject is young, there is greater 
probability that induration may exist. We should also have a 
regard to glandular engorgements ; thus, in the vegetations which 
do not succeed to a chancre nor to a blennorrhagia, there is no 
glandular enlargement. When cancer of the penis exists in its 
early stages, there is almost always a very hard and indolent en- 
larged gland, before it undergoes the process of softening. But 
here, as in all other cases, this circumstance should be noted, with- 
out attaching to it too great importance. Glandular enlargements 
are among the most common causes of mistakes in diagnosis. 

Causes. — Blennorrhagia, balano-posthitis, and chancre, are the 
principal causes of vegetations ; thus they may shoot forth at a 
point of the integuments only, that has been inflamed, excoriated 
or ulcerated ; in fine, vegetations may be the first as well as the 
last symptoms of contagion. We see vegetations succeeding im- 
mediately to posthitis, we know that they may shoot forth on the 
cicatrix of a chancre, and they may appear on the glans without 
inflammation or previous ulceration ; the same may occur at the 
anus. As a consecutive accident, they may occur at any period 
of syphilitic infection. I have now in my service, three patients 
with vegetations around the anus; one of them is young, and 
has acknowledged unnatural connexion; the second, for three 
months has had a chancre on the penis ; and the third has 
also had a chancre on the same organ ; but for five years his sys- 
tem has been fully infected, and the vegetations have been the 
last to appear. Vegetations may, therefore, belong both to the 
primary, and the consecutive accidents. 

Nature. — It has been maintained that they are not of venereal 
origin. According to some writers on syphilis, they are but 
parasitic growths generated under the influence of the irritation 
excited by a blennorrhagia or chancre, or produced by some other 
irritating cause, as for example, the irritating discharges secreted 
by the genital organs of the pregnant female. I deny that any 
irritating cause may give rise to them ; there are cases, indeed, in 
which they shoot forth, without any previous irritation. We 
never find a vegetation appearing without an antecedent, without 
venereal accidents, without some preceding intimate connection. 
Thus irritation of the glans and the prepuce without sexual inter- 
course is not uncommon in very young boys ; vulvar inflamma- 
tions are often observed in young virgin girls ; yet we never find 
vegetations occurring at this age, nor after this kind of inflamma- 
tion. But if the subject has had connection, the case is different ; 
then, vegetations may shoot forth from the slightest irritation. 
Again, the syphilitic nature of the vegetations is incontestable, 
when they appear as consecutive accidents, long after the chancre 
that preceded them. There is another argument against the doc- 



VEGETATIONS. 259 

trine that these vegetations are the result of simple irritation ; and 
that is, their very decided tendency to reproduction. 

Transmissibility. — This is now placed beyond doubt, by the ob- 
servations of the majority of writers on syphilis, and especially of 
MM. Baumes and Eeynard (of Toulon). The latter thus remarks : 
11 Incontestable facts prove that the form of syphilis which I am 
now considering (vegetation), without being so uniformly conta- 
geous as chancres, are capable of being directly transmitted."* I 
am at present treating a young girl who had connection for the 
first time with a man affected with vegetations on the corona 
glandis ; she has vegetations on the vulva, and these have been 
preceded by no other symptoms. I should remark, that the vege- 
tations on the young man grew on the cicatrix of an indurated 
chancre, but the chancre had been completely cured for two years. 

Treatment. — This is both general and local. Those who pretend 
that vegetations are not caused by the syphilitic virus reject the 
general treatment, and proscribe mercury. Those, on the contrary, 
who believe in the specific character of these morbid growths, re- 
commend a general treatment. The remedies indicated may be 
inferred from the circumstances in which they are developed. I 
have shown that they may appear in all stages of syphilis, and 
that they may be the first apparent symptom of infection. JSTow 
when they appear during the existence of a diathesis, they are 
rarely alone, but are accompanied by other accidents requiring a 
general treatment ; hence all doubts of the propriety of the latter 
are removed. Sometimes, they appear after all the other accidents, 
and then general treatment has in most cases already been adopted, 
and this has consisted either of the preparations of mercury or of 
iodine. Constitutional remedies may now produce no effect : the 
vegetations have become localized, they no longer have deep roots, 
but are a kind of remnant of the disease. Topical treatment, 
trifling surgical operations, should now be preferred ; for if entirely 
extirpated, they do not return, as is so often observed under other 
circumstances. 

"When vegetations are primary, when they constitute the first ap- 
parent symptom of the infection, we should still pursue a general 
treatment, if we would not expose the patient to the liability of 
frequent returns, and if we desire to prevent complications. More- 
over, facts go to show the efficacy of a general treatment ; a re- 
markable instance may be found in the work already mentioned 
of M. Eeynard (of Toulon).-)- Under the influence of the concen- 
trated syrup of sarsaparilla, with the addition of the corrosive sub- 
limate and the extract of opium, in fifteen days well-marked vege- 
tations will become softened within, and drop off, no more to re- 
turn. I shall never forget the case of a young girl I found in the 
ward of St. Louis when I entered on service at the Lourcine. Both 
the labia majora and the labia minora were covered with small 
vegetations which produced an intolerable pruritus, and even severe 

* Traite pratique dcs maladies vcneriennes, p. 810. 
f P. 312. 



200 VIDAL ON VENEREAL DISEASES. 

pain. All kinds of powder and ointments had been employed ; 
some of the vegetations had been removed with the knife, but had 
reappeared, whilst the others remained. No general treatment had 
been undertaken; mercury had not been administered, perhaps 
because the young patient was feeble and of a lymphatic tempera- 
ment. I thought best, however, to prescribe Dupuytren's pills, 
and in less than twenty days the vegetations began to wither, 
and by degrees they fell off spontaneously. I have observed other 
cases of the kind, but truth compels me to admit that vegetations 
most frequently remain in spite of general treatment. We must 
therefore resort to topical treatment, to the ligature, and to excision. 
There are numerous topical applications which have been greatly 
multiplied on account of nervous patients who dread anything 
like an operation. Saturated solutions of opium, crude opium, 
iodide of iron, sulphate of copper, and calomel, have all been used. 
The most successful method is the following : 

5- Savine, 3 i. 

Alum, C ale, 3!. 

Reduce to a very fine powder. Wash the vegetations twice a day with 
red wine ; cover them aftenvards with a thick layer of the powder. In the 
course of three or four days the vegetations become feeble, and the patient 
?nay begin to remove them ivith his finger nails. After each separation, 
there is a slight bloody discharge, which may be arrested by the vinous 
lotion, after which the powder is reapplied. 

"When the vegetations are not very numerous, and have not a 
large base, this method is successful, and the patients are delighted 
to operate on themselves, and to cheat as it were the hands and 
knives of the surgeon. 

Some practitioners prefer cauterization; for this purpose, the 
nitric and the hydrochloric acids, the nitrate of silver, and the 
butter of antimony, have been employed. That most used at 
the present day, and which is the most efficacious, is the nitrate 
acid of mercury. A vegetable, silk, or silver ligature has also 
been used, but this method, tedious in its effects, equally painful 
with cauterization or excision, is now generally abandoned by 
surgeons. Some patients still submit to it ; they gradually tighten 
the knot, and as they themselves operate, and can suspend its 
action when they please, they actually suffer more than they 
would under the hands of another. But topical applications 
cannot reach the root of the vegetations; if with ligature or 
caustic, we act to such a depth, we should produce most violent 
pain, and of longer duration than that resulting from excision. A 
cutting instrument should therefore be preferred when we have 
reason to suspect that the roots of the vegetations are not very 
deep, when their base is large, and when, in fine, we would pre- 
vent a return. A forceps may be used to seize the vegetation, 
and it may be excised with flat curved scissors. When it is some- 
what large, but little prominent, as we often find on the genital 
organs of the female, it is sometimes difficult to seize it, it glides 



MUCOUS TUBERCLE. 261 

between the blades. I use small forceps (a dents de rat), which 
will embrace the quantity and only the quantity of the mucous 
membrane required to be removed around the vegetation, and 
this is extirpated without being torn. My rat-toothed forceps are 
much employed by oculists in their operations on the eye-lids and 
the eye. Some surgeons cauterize the wound left by the opera- 
tion ; but it is unnecessary if the limits of the skin have been sur- 
passed ; if they have not been passed, then the extirpation has not 
been well performed ; if we resort to caustic, then we inflict two 
operations. It is better to seize the whole thickness of the integu- 
ments, and not be too saving of the parts removed. Especially 
should this rule be followed, if the integuments be more or less 
altered and thickened, either by the venereal affection on which the 
vegetation has sprouted, or by its age, which by long irritation of 
the skin, has developed on its tissue a hypertrophic action. 

After the operation, blood often flows in great abundance, 
especially when the excrescence is seated on the glans. Cold ap- 
plications should be applied at first, and the parts should after- 
wards be dressed as in the case of a simple wound. It should be 
well understood that extirpation is not to be attempted, if there 
exist chancres which have not healed, for the wound may then be 
inoculated. As a general rule, we should not operate until all 
complications are removed. However, there is often around the 
vegetations an irritation, an inflammation even, that subsides only 
when these excrescences have been removed. 



CHAPTER VIII. 

MUCOUS TUBERCLES. 



These are also called, according to their aspect and form, flat 
pustules, flat tubercles, mucous pustules, mucous patches or papules, 
[and condylomata. — Gr. C. B.] They consist of elevations of which 
we may have a very correct idea if we imagine the application of 
disks more or less perfect, or portions of a disk, to the integuments. 

Situation. — These tubercles form on the mucous membranes and 
portions of skin which, either naturally or from disease, resemble 
mucous membrane : thus, the skin on the genital organs, on the 
parts adjacent, and at the bend of the thigh. In the female, they 
are more frequently observed on the vulva ; whilst in the male, 
they are found at the margin of the anus. The scrotum, penis, 
perineum, are also frequently affected. They have been observed 
at the genito-crural fold, at the umbilicus, in the external auditory 
canal, and behind the pavilion of the ear, in the axilla, the mouth, 
the commissures of the lips, on the tongue, the internal surface of 
the cheeks, on the tonsils, and the walls of the palate, at the en- 
trance of the nostrils, the alae of the nose, the base of the toes, 
around the nails, the nipples, and the neck of the uterus. These 



262 VIDAL ON VENEREAL DISEASES. 

tubercles may occupy nearly all of these regions, on the same 
subject, and assume all the forms which I shall soon describe. 
At present (March 16th, 1852,) there is in my service a man forty 
years of age, who has tubercles on his ears, nose, lips, tongue, 
right axilla, at the genito-crural fold, on the scrotum, perineum, 
anus, and between his toes. 

Causes. — Mucous tubercles are more frequently observed in 
females, owing perhaps to the extent of the mucous membrane 
lining their genital organs, and the delicacy of their skin ; children 
and lymphatic subjects are also strongly predisposed. Want of 
cleanliness is favorable to their development: indeed, a female 
seldom comes to the Lourcine from the country, in whom mucous 
tubercles do not exist. Corpulent persons, whose acrid perspira- 
tion accumulates in the genital fold, the irritation produced around 
the margin of the anus by prolonged walking, and especially by 
constipation, are among the causes which favor the development 
of those venereal accidents. The surface of the integument fre- 
quently exposed to the action of the matter discharged in blennor- 
rhagia, is sometimes covered with mucous tubercles. It is ad- 
mitted, that chancre may be transformed into a mucous tubercle, 
and this too at the moment when a chancre is healing, but healing 
irregularly ; in such a case, the tubercle is only a transformation 
of the chancre. The truth is, that a tubercle may appear even at 
the point where a chancre is seated, as it may appear on a surface 
simply inflamed ; such sometimes being the result of a balano- 
posthitis. It may therefore be regarded as a consecutive accident, 
but it may, likewise, be altogether primary ; in other words, it 
may be the first accident observed to follow a suspicious con- 
nection. 

In females, the mucous tubercle most frequently exists as a 
primary symptom ; in the male, on the contrary, it is generally 
found to follow a chancre on the penis and urethral blennorrhagia, 
whilst it is itself followed, some time afterwards, by the same dis- 
ease at the anus. This, moreover, is one of the accidents which 
most compromises the classification of diseases, the syphilitic acci- 
dents, into primary and secondary, if we attach to this classification 
a doctrinal and absolute sense. 

Symptoms. — The mucous tubercle may appear one or two weeks 
after coitus, and often during the existence of chancres, or of blen- 
norrhagia. Sometimes there is a period of incubation of two or 
three months, and even longer. Occasionally they appear at once 
(d'emblee) ; they then constitute the first symptom of the pox. 

They resemble disks, or portions of a disk, glued on the surface 
of the integuments. Sometimes they have an oval form. The 
smallest are simple papules which increase to the size of a lentil ; 
the largest, the true clusters, seldom exceed the size of an Ameri- 
can dime (fifty centime piece). When several pustules come 
together and become confounded into one, they may be of very 
large size. 

Instead of remaining in the state of patches adhering by one 
entire surface, these excrescences, especially when of long standing, 










Fi6 I 



i 









</^/. 2.t. /^/^ 



^„> /£ ^ /// /W . ^ *ws»s* '////? 



- : 



MUCOUS TUBERCLE. 263 

become now and then detached and pediculated, assuming the 
form of the vegetations in condyloma. Thus, in the patient to 
"which I have alluded, who was almost covered with tubercles, 
those in the axilla and the genito-crural fold strongly resembled 
the vegetations of which I have spoken. 

When seated on the mucous membranes, the color is more or 
less of a lively red, whilst on the skin, in the majority of cases, 
they are brown. Around them the coppery areola of the syphilitic 
eruptions is often observed. The surface is sometimes smooth, 
slightly fungous, and sometimes presents a macerated appearance. 
Occasionally they are completely fungous, and of a violet color. 
In persons of a brownish color, even when they grow on the skin, 
they are fissured, and appear as if irritated. They may have an 
eroded and even ulcerated surface, resembling that of chancre, 
especially that form known as the ulcus elevatum. 

They generally secrete a serous like, or sero-purulent fluid, 
which has a peculiar and repulsive odor. The pus becomes more 
strongly marked as the ulceration is established and the pustules 
are irritated. 

Seldom do the mucous tubercles exist alone, especially about 
the anus and the vulva. They may be extremely numerous, and 
as I have already stated, occupy several regions ; generally they 
occur in groups, or are arranged in order, on a line more or less 
curved : thus, they will appear on the edge of one of the labia, or 
on one side of the nates. Then, in the majority of cases, if the 
person be careless, we observe on one of the labia or nates, tuber- 
cles precisely like those on the opposite side. It is not uncommon 
to find two, one of which seems moulded on the other, to such a 
degree as to resemble the valves of a shell. This resemblance of 
two tubercles, situated on organs adjacent to each other, is another 
argument in favor of the contagion of this form of syphilis. (Yid. 
Plate IY. Fig. 2.) 

In this symptomatology I have particularly dwelt on the charac- 
ters of those most known, viz. those on the genital organs and 
around the anus. There are others less known, either from their 
infrequency, or because they are so situated as never to lead to the 
suspicion of their existence, or, in fine, because their characters are 
less marked, and probably, also, because, up to the present time 
they have not been described. I proceed to point out the appear- 
ances by which they may be known, which will complete the 
general sketch and facilitate their diagnosis. 

In the nasal region they may be found either without or within 
the nostrils, and at first resemble those at the angles of the lips ; 
they are seated in the groove that separates the cheek from the ala 
of the nose. They are of smaller size than those on the lips, being 
occasionally not larger than the head of a pin. Sometimes we 
find in the groove above mentioned an elongated scale, which is 
very thin, ulcerated, and transformed into a fissure. After this 
has healed, there remains a dark red shade, which cannot deceive 
the observing physician, and which may become a precious sign in 
forming a diagnosis. Within the nostrils, or at their entrance, these 



264 VIDAL ON VENEREAL DISEASES. 

layers are less frequently observed ; they generally form a swelling 
with, crusts, the fall of which exposes a red and gray surface, then 
the crusts are renewed until a cure is completed. The cure is 
retarded by the excoriations produced by the patient in his efforts 
to relieve the itching. 

On the toes and around the root of the nails, the tubercle has 
nearly the same characters. Almost always the patches are ulcer- 
ated and resemble rhagades of the anus. The most prominent 
portion is of a bluish color and round between the toes. They are 
elongated at the root of the nails and follow the direction of their 
base. The ulceration differs in the two cases. Around the nails, 
they are irregular fissures, with edges more or less turned over on 
the nails. These layers are painful and emit the most fetid odor, 
when the patient does not observe cleanliness. They are very 
speedily affected, and are quickly cured. 

In the aural region, it occurs at the junction of the concha with 
the mastoid region, around the auditory canal, and assume the 
form of the swelling which we find at the entrance of the nostrils. 
It may also be found even in the auditory canal. 

On the neck of the uterus, it is often of a reddish gray color, very 
round, distinct, and a little larger than a lintel. It has been seen, 
at the same time, on both the upper and lower lip. 

At the umbilicus, the patch occupies in part or entirely the um- 
bilical depression; it is ordinarily prominent, of a reddish-gray 
color, humid, and of a sickening odor. Sometimes there is pruritus, 
but rarely pain. 

Around the nipple we sometimes find an excavation, lined by a 
layer which somewhat overlaps it ; it has a grayish aspect, is humid, 
smooth, and there is an oozing of muco-purulent matter. 

In the buccal region, the mucous tubercle is constantly seated on 
the external border of the lips, at the commissures, and on the 
internal surface of the cheeks ; on -the edges of the lips are little 
projections, generally, of an elliptical form, varying in number and 
covered with crusts. They frequently exist undetected, and often 
disappear but readily return. These patches almost always co- 
exist with a similar condition of the throat and the genital organs. 

At the labial commissures it is of a granulated aspect ; there are 
at least two of nearly equal size, one on the superior, one on the 
inferior lip ; one fissure separates them, a fissure that remains after 
the removal of the patches. These are likewise very often undis- 
covered. We see nothing but the fissure which is regarded as 
being independent of syphilis. 

On the tongue, we find patches on the apex, the base and borders, 
They are very large, of an elliptical form, and sometimes ulcerate. 
In the female these patches almost always coincide with a similar 
affection of the vulva. 

On the velum palati and tonsils, mucous tubercles are of frequent 
occurrence, especially on the latter. They often escape detection 
at their origin, for then they are not prominent ; they are round, 
multiple, sometimes confluent, and almost always of a grayish- 
white color. Occasionally they ulcerate at the centre, or at other 






MUCOUS TUBERCLE. 265 

points of their surface. The tonsils are often enlarged and of a 
red color, which spreads to the surrounding parts. With the 
patches in this region there exists symptoms of angina, pain in the 
throat, exasperated by deglutition, catarrh, and a little coryza. 

In the axilla, where pustules are rare, they are sometimes seen 
prominent and a little pediculated.* 

Diagnosis. — The description which I have given constitutes a 
true diagnosis. The ulcus elevatum alone can be confounded with 
the tubercle in question. But this form of chancre general^ ap- 
pears on the edge of the prepuce, where tubercles are not common, 
and it is preceded by a true ulceration ; besides, it requires a much 
longer time for its cure. 

[There is one point connected with the diagnosis of the mucous 
tubercle to which for a moment we solicit the reader's attention. 
Waller, who is at the head of a large venereal hospital at Prague, 
has reported, among other cases, that of a nurse named Watzka, 
who became affected by suckling a syphilitic child. In describing 
the mucous tubercles which formed on this nurse's breast, he 
states that the one on the right breast was of the size of a bean ; 
that on the left of a pea, and that they rested on a broad base. 
M. Hicord would impeach the accuracy of Waller's diagnosis, On 
the ground that they rested on a broad base, and asserts (Letter 
xxix., p. 221) he knows not what may be regarded as mucous tu- 
bercles at Prague ; but at Paris, those described by M. Waller 
would be considered as very excellent specimens of indurated 
chancre with a broad base ! The nurse's nipples became affected 
from mucous tubercles on the child's lips. Now let us examine 
a few French authorities upon the subject of this broad base of 
mucous tubercles. 

In the Bibliotheque du Medicin Praticien, vol. vii., p. 260, it is 
stated that " mucous tubercles vary in breadth from the simple 
papule, the size of a lentil, to a tubercle as large as a half dime 
or dime piece. Again, at page 261, quoting from MM. Baumes 
and Reynaud, we find that their volume varies from that of a small 
lentil to a dime piece." 

M. Rayer (Lond. Ed. by Dr. Willis, p. 812) observes, " that these 
tubercles attain a size but little less than that of a shilling" (Eng- 
lish). At p. 813 he remarks, that when situated on the breast 
they sometimes ulcerate to a greater extent than they are ever ob- 
served to do in any other part of the body." 

M. Cazenave (Bulkley's 2d. Ed. from Transl. by Dr. Burgess, pp. 
303, 304) states that "these tubercles are occasionally as small as 
lentils, at other times thick, of a deep livid red color, and as large 
at the base as a shilling" (English). 

M. Simon (Ghistav.) in his work "On the Diseases of the Skin, 
as elucidated by Anatomical Investigation," Berlin, 18-18, {Med. 
Ohir. Review, April, 1849, p. 357,) says, "the diameter of the broad 
condylomata (mucous tubercles) varies from that of a lentil to that 

* Vide, a memoir of MM. Deville and Davasse in the Archives generates de medc- 



•266 YIDAL OX VENEREAL DISEASES. 

of a groschen (in size equal to the American quarter eagle, or $2.50 
gold piece). 

M. Ricord's contempt of the diagnosis made by M. Waller in 
the above case, arises solely from the fact of his (M. Ricord's) op- 
position to the doctrine of the transmissibility of secondary acci- 
dents, and all who do not join in his faith must suffer from his un- 
sparing sarcasm and ridicule. — Gr. C. B.] 

Contagion. — Inoculation. — The contagious character of the mu- 
cous|tuhercle ; in other words, its transmissibility from one indi- 
vidual to another by intimate contact, is generally admitted, since 
it is almost universally acknowledged that it may be a primary 
accident. M. Ricord is, with but few exceptions, the only writer 
on syphilis that denies its contagious nature. Nevertheless we 
find certain doubts expressed in his work, certain contradictions 
which would place him among the contagionists. However this 
may be, those practitioners who have the opportunity of seeing 
both together, know what credit to attach to the contagiousness 
of these pustules. They will see on the left side of the scrotum a 
flat tubercle resembling that on the right side of the vulva with 
which the man had had frequent connections. I retained for a 
long time in my service a patient affected with the mucous tuber- 
cles at the margin of the anus, of which I have had a sketch 
taken ; those on the right nates seem moulded on those of the op- 
posite side, as represented in plate 4, fig. 2. The following is a 
report of the case made by Mr. Pellagot, one of my internes. This 
case shows not only the remarkable relation existing between the 
tubercles on both sides of the anus, but it is an excellent example 
of the multiplicity of the syphilida on the same subject. 

Gr. (Alain,) set. 25, currier by trade, of bilious temperament, and 
good constitution. Admitted 3d Nov. 1851, into Ward 9. bed 
No. t 

1845. Blennorrhagia, which lasted six months. Treated by 
copaiba. 

1849, (Sept.) Blennorrhagia and chancre on the prepuce. The 
former lasted two months, and was treated by cubebs. The 
chancre was cauterized by the nitrate of silver. At the end of 
about fifteen days it was cicatrized. No other treatment. 

1850, (October.) Blennorrhagia, chancre on the glans, suppurat- 
ing bubo in the right groin. The patient was treated at the hos- 
pital at Nantes. For a month he took a fluid which he believed 
to be a solution of iodine. 

1851, (August.) A warty excrescence was developed on the 
skin of the penis, at the very place where a chancre had pre- 
viously existed. Two others, smaller than the first, grew on the 
edge of the prepuce. They appeared four or five days after the 
last coitus. 

Eight or ten days after the appearance of these vegetations he 
had a urethral blennorrhagia. The patient is positive that there 
was no abrasion on the glans ; for fifteen days he has observed 
absolute continence. 

Six weeks after the vegetations, three weeks after the urethritis, 



MUCOUS TUBERCLE. 267 

mucous tubercles appeared on the scrotum and at the anus. 
Balanitis, followed by phimosis. At the same time an exanthe- 
matous syphilitic eruption. Finally, twelve days since, there was 
a lichenoid eruption and alopecia. On the 3d Sept., at the time 
of his admission, in addition to the vegetations on the prepuce, 
the urethral and balanitic discharge, the patient still presented 
various kinds of eruptions. On the lower extremities, and the 
arm, copper-colored spots without elevation, having had at first a 
rosy color for the extent of a franc piece. These spots are parti- 
cularly remarkable on the legs, where they are - more numerous 
and larger than elsewhere. On the chest and the forehead lich- 
enoid eruptions ; . on the neck squamae of psoriasis, and on the 
whole side crusts of the pustules of ecthyma. 

Finally, on the scrotum, and at the anus, mucous tubercles 
abound. At the anus, especially, these excrescences assume a re- 
markable disposition. There is indeed the closest resemblance 
between the tubercles on the right and those on the left side. 
The patient declares that their appearance was not simultaneous, 
but that there was some days interval. On the 5th he was placed 
under the influence of pills of the proto-iodide of mercury, and in 
three months the patient left, cured. (Vide Fig. 2, Plate 4). 

For a long time experiment has corroborated the results of ob- 
servation, and "Wallace repeatedly inoculated the mucous tubercle 
from a diseased to a sound subject with success. And yet, not- 
withstanding our frequent and easy communication with Dublin, 
attempts have been made in France to conceal the results obtained 
in that city ! .Wallace denuded the skin, by a blister or other- 
wise, and applied to the denuded surface portions of the mucous 
tubercle, or charpie impregnated with the matter secreted; he 
thus produced, almost at pleasure, tubercles which varied in form, 
but which belonged to the class of accidents called secondary. 

M. Bouley, a hospital physician, whose attention was aroused 
by my experiments in inoculating syphilitic ecthyma, undertook 
with M. Schneph some bibliographical researches and experiments, 
which form a part of an elaborate memoir published in the Annates 
des maladies de la peau et de la syphilis, (vol. iv., Oct. and Nov., 
1851.) This memoir contains the report of numerous cases, copied 
from the work of Wallace ; they leave no doubt whatever of the 
transmissibility of the mucous and of other tubercles belonging to 
the class of accidents called secondary. The memoir is invaluable, 
particularly on account of a case reported under the supervision 
of M. Bouley, by M. Schneph, interne at the Lourcine. This 
case, which cannot be too frequently studied, itself resolves two 
questions of the highest importance, for it proves : 1st, that the 
mucous tubercle may be inoculated ; 2d, that a subject that has 
been completely infected with syphilis, and passed through all the 
different stages of the disease, may have a second attack. The 
following is a synopsis of the report : 

Patient, a female, at the Lourcine (service of M. Bouley). Had 
suffered from constitutional syphilis, as was manifested by disease 
of the fibrous and osseous systems ; she had gummy tumors and 



268 YIBAL ON VENEREAL DISEASES. 

necrosis. A blister was applied to the arm, and, after the removal 
of the epidermis, for three days it was dressed with charpie im- 
pregnated with the secretion of mucous tubercles on another pa- 
tient in the same hospital. On the fifth day after the inoculation, 
the blistered surface had healed; but on the seventeenth day, 
lenticular pimples, of a copper color, covered the blistered part ; 
on the twenty-seventh, crusts appeared, and the eruption was pro- 
nounced ecthyma by M. Cullerier, which by M. Cazenave was re- 
garded as syphilitic. A second blister, dressed simply, and not 
inoculated, promptly dried, and was followed by no eruption. 

There was here, therefore, as in other cases of inoculation that I 
have known, a long incubation. It lasted seventeen days. A 
constitutional syphilitic accident afterwards appeared, but in a 
form less profound than the patient had already experienced; 
since the accident inoculated was a syphilitic eruption, a cutaneous 
affection, whilst the others involved the fibrous and osseons sys- 
tems. Further, forty-eight hours after inoculation, there followed 
a syphilitic fever, connected with the new infection. There was 
intense cephalalgia, the crusts of the ecthyma remained, and there 
was an appearance of tumors in the subcutaneous cellular tissue, 
together with a kind of imperfectly-defined nodes, like those on 
the female from whom the matter was taken for inoculation. This 
new syphilitic excitement was advantageously modified by mer- 
cury, although it had resisted the iodide of potassium. 

Thus, I repeat, this case at once destroys two dogmas : — 1st, 
that of the non-transmissibility of syphilis in its secondary form ; 
2d, that which proclaims that syphilis cannot affeet an individual 
but once during life. 

"Waller, physician to the hospital at Prague, has inoculated by 
another proceeding : instead of removing the skin by a blister, he 
scarified the parts. The subject inoculated was a young lad who 
had never suffered the slightest venereal symptom. The matter 
of inoculation was taken from a subject affected with mucous 
tubercles. Charpie was impregnated with the secretion of these 
pustules, and applied to the little wounds already made on the 
thigh of the young lad. The whole was secured by dressing, pest 
occlusion, that prevented the contact of any other substance than 
the charpie saturated with the morbid secretion. There was at 
first a little inflammation, or, to speak more properly, some red- 
ness, which disappeared at the end of four days ; finally, it was 
not until the twenty-eighth day from the inoculation, that tuber- 
cles and papules appeared at the place of inoculation, and symp- 
toms of general infection. 

There were, in this case, at first, inflammatory phenomena, 
which were soon extinguished, an eruption which aborted, and, 
some time afterwards, the effects of the virus were produced in the 
most incontestable manner. We may often meet with analogous 
cases ; the eruption which first appears may abort, and after this 
the true syphilitic eruption is observed to follow. 

[There is abundant proof, as we have already shown, that inocu- 
lation with the matter of chancre does not always produce the 



MUCOUS TUBERCLE. 269 

same invariable result, the so-called characteristic pustule ; and 
such, as might be expected, is the case with that of secondary acci- 
dents — as, for example, the mucous tubercle. "We have mentioned 
the fact that Dr. Skae, of Edinburgh, in four out of thirty-six in- 
oculations of the matter from mucous tubercles, produced positive 
results, but, u in the only cases in which my inoculations suc- 
ceeded, the effect took place within one or two days," (Cormack's 
Lond. and Ed. Month. Journal, July, 1844, p. 620.) " In all of 
these, the first appearance presented in the seat of the inoculation 
was a pustule on the second or third day, as in inoculating from a 
chancre. At length a scab formed, which appeared to be seated 
on sores depressed below the level of the adjoining surface, but 
without the elevated or hardened edges, or the defined circular 
form of chancre. These continued to increase in size, preserving 
the same appearance and covering, until they met each other and 
coalesced. On the 14th day, these crusts became detached, and a 
fungoid excrescence, having all the appearance of a condyloma, 
shot up from the sore." We quote from the abridged account of 
Dr. Skae's article, which originally appeared in the Northern Jour- 
nal of Medicine for April, 1844. — G\ C. B.] 

Whoever peruses the remarkable work of Waller,* may see 
with what rigorous precision he has selected the elements of cer- 
tainty, when, from his own clinical observations, he remarks: 
" Strongly as the above cases show the great probability of the 
contagious nature of secondary syphilis, I could not and would 
not rely on them alone ; I sought, certainty, and believed that it 
could be found only in inoculation. The following is the princi- 
pal instance of inoculation : 

" Durst, get. 12, ISTo. 1396, for several years was affected with 
tinea favosa, of the head, a disease for which he had been several 
times treated in the institution ; his health is perfectly good, and 
he never had an eruption of any kind, nor was he ever troubled 
with scrofulous affections. As his disease compelled him to re- 
main for several months in the building, and as he had never had 
syphilis, he was considered a proper subject for inoculation : which 
was performed on the 6th August, 1850. A scarificator, perfectly 
clean, was applied to the anterior surface of the right thigh, and 
into the wounds thus made, still fresh and bleeding, pus from 
mucous tubercles was inserted. For this purpose, a narrow 
wooden spatula was employed, together with charpie saturated 
with pus, which was gently rubbed on the surface of the wounds, 
and which was afterwards there deposited and secured. The mat- 
ter for inoculation was taken from a woman (named JSTemee), who, 
indeed, presented the cicatrix of a chancre, but who, at the time, 
had no primary sore. On the labia majora and minora there were 
mucous pustules, covered with an exudation partly croupy, partly 
purulent. These croupy exudations, besides, existed throughout 

* De caractcre contagieux de la syphilis secondaire, by Dr. Waller, translated into 
French, by M. Axenfeld, in the Annates des maladies de la pcau et de la syphilis, 
April, 1851, and Gazette des Hbpitaux, for the same date, by M. See. 



270 VIDAL ON VENEREAL DISEASES. 

the throat, and in the commencement were attended with an ulcer- 
ation of the tonsils ; an eruption of blotches covered the whole 
body. This woman, at the same time, had a vaginal blennor- 
rhea. 

"On the next day, August 7th, and the following days, the 
wounds made by the scarifier and the intermediate skin, were 
slightly inflamed ; but at the end of four days the wounds were 
all closed : there was no trace of inflammation, and the whole sur- 
face in general resembled that which has healed after scarification. 

" On the 15th August, I remarked at the seat of inoculation, 
some red, spots, and on the 30th August, consequently twenty-five 
days after inoculation, I discovered fourteen cutaneous tubercles, 
the majority of which had arisen even in the cicatrices of the 
wounds. These tubercles were almost all confluent ; four only 
situated on the edges were isolated ; their base was large, their 
size that of a lentil, in many that of a pea ; hard to the touch ; 
most were of a deep red, some of a deep yellow color ; their form 
was perfectly round ; on some there was a slight desquamation ; 
nothing abnormal in the other parts of the body — (no treatment). 
On the following days, the tubercles still increased in volume, and 
became blended together ; they then represented a patch about the 
width of a dollar (thaler), were soft, projecting half a line above 
the level of the skin, and covered with grayish scales, which be- 
came thickened and finished by forming the large crust common 
to tubercles. In cleaning this surface with hot water, the crust 
became detached, and the tubercles then appeared under the form 
of flattened elevations, slightly excoriated, but which were promptly 
covered with new, thin, dry, and grayish scales. 

" The 27th September, twenty-seven days after the appearance 
of the tubercles, and fifty -two after inoculation, a maculated syphi- 
litic eruption appeared on the skin covering the lower part of the 
abdomen, chest, and back. 

" These spots were for the most part united, some were a little 
prominent, isolated, of the breadth of a millet-seed or a lentil, of 
an oval and elongated form, some of a pale yellow, others of a 
reddish-gray tinge, without areola, itching or pain, completely 
dry, without crusts and scales. The next day, and the follow- 
ing, the number of these spots prodigiously increased, and the 
whole body was covered. There was no febrile disturbance nor 
was there any symptom of catarrh, &c. In the early part of Octo- 
ber, some of these spots became elevated into pimples, others into 
tubercles, and altogether had a physiognomy so characteristic, that 
without inquiring into the antecedents, any physician would at 
once have pronounced them to be syphilitic. There was no affec- 
tion of the throat ; but as this papular and tubercular eruption 
sufficiently proved the success of the inoculation, I now feel jus- 
tified in giving publicity to the case." 

I still repeat that there was here, between the inoculation of the 
secondary accidents, and the true results of the infection, a period 
which is not observed to follow the inoculation of chancre. And 
I would here especially remark, that the wounds for the inocula- 



MUCOUS TUBERCLE. 271 

tion were dressed with, charpie, and that they were thus guarded 
against any other fortuitous inoculation. 

When I come to treat of ecthyma, I shall detail the facts con- 
nected with the inoculation of this secondary accident, which will 
present the same peculiarities. Occasionally nothing appears on 
the point inoculated for a long time, the true syphilitic eruption 
being the first to manifest itself 

The case which I am about to relate, in detail, the particulars 
of which were carefully collected by my former interne, M. Pella- 
got, differs from those which have been published by the experi- 
menters whom I have quoted. We here find the morbid secre- 
tion of a mucous tubercle producing in the first place a most 
abundant and most fetid suppuration, then an ulceration, and 
lastly, a patch analogous to a mucous tubercle. As it has been 
pretended that the blistered surfaces, which after the inoculation 
became transformed into tubercles, were nothing more than vege- 
tating blistered surfaces, I was careful to make the counter proof ; 
on the right arm, indeed, we observed a blistered surface, which 
on being irritated for four days with strong blistering ointment, 
desiccated, healed without ulceration, or papules, whilst the same 
surface dressed only twice a day with the morbid secretion, be- 
came the seat of the most active inflammation, of an ulceration, 
in fine, and of a patch analogous to mucous tubercles. In addi- 
tion to the students who ordinarily attend my visits, the subject of 
these experiments was seen by Drs. Morel, Chausit, Auzias, Tur- 
enne, and M. Gosselin. 

P. ast. 19, tinsmith, temperament lymphatic, constitution very 
good, was admitted, July 17th, 1851, into Ward No. 10, bed No. 
1, service of M. Vidal. Had had no previous venereal disease ; 
Four or five months since had a chancre on the corona glandis. 
This chancre lasted a month, after which it cicatrized. An indu- 
ration remained in the situation of the chancre. Itchings begin to 
be felt about the anus, and mucous tubercles to appear. 

Present condition. — On the glans, where the chancre was seated, 
the mucous membrane is red, thickened, and unbroken. Between 
the glans and the prepuce, there exudes a very thin scanty sero- 
purulent fluid. Two inguinal glands much developed, on the 
right side, a small one on the left. The whole are indolent. The 
sub-maxillary and anterior cervical glands enlarged. Posterior 
cervical glands not visible. About the anus are three mucous 
clusters non-ulcerated. Up to the present time has submitted to 
no treatment. 

On Thursday, July 24th, a small blister was applied to the left 
arm. It was covered with a watch-glass. Pills of mica panis. 

Friday, July 25th, first dressing. The epidermis raised by the 
blister is removed. A disk of blotting-paper covered with cerate, 
with an opening in the centre, of one and a half centimetres in di- 
ameter, is so applied to the wound as to secure the margins. The 
central part is dressed with carded cotton saturated with pus 
taken at the moment of dressing from mucous tubercles about the 
anus of a patient, in bed No. 38, of Ward No. 8, service of M. 



272 TIDAL ON VENEREAL DISEASES. 

Puche. The whole is covered with a watch-glass, and secured by 
straps of diachylon plaster.* 

Saturday, July 26th. Second and last dressing with the same 
pus as before. The old dressing is removed. Suppuration con- 
siderable. The odor resembles that from mucous tubercles. The 
wound is converted into a whitish diphtheritic-like pellicle, with 
black spots at certain points. In removing this pellicle, which ad- 
heres, and is torn by pulling, a slight bloody exudation is pro- 
duced. The edges of the watch-glass have cut the skin and pro- 
duced at its upper part a superficial excoriation which is distinct 
from that produced by the blister. 

Sunday, July 27th. The solution of continuity which was be- 
fore superficial, is deepened and has assumed the form of an ulcer, 
the edges of which are perpendicular to the base. The latter is of 
a yellowish-white color, and secretes a large quantity of well- 
formed pus, but of an intolerable fetor. In wiping with a compress 
the surface of the wound, we remove in part the false membrane 
that covers it, and then there is a little bloody exudation. The 
excoriation, produced by the edges of the watch-glass is converted 
into a deep notch which suppurates abundantly. The watch-glass 
is no longer used. Simple dressing with cerate. 

28th. The ulcers remains the same. It secretes an enormous 
quantity of pus always very odoriferous. The edges are red, per- 
pendicular, and the base of the sore yellow. No enlarged glands 
are felt in the axilla. Simple dressing with cerate, and renewed 
twice a day. 

30th, 31st. The wound retains the same characters ; the sup- 
puration always abundant and nauseous. Dressed night and 
morning. 

August 1st. A blister similar to that on the left is applied to the 
right arm, and like the latter is covered with the watch-glass. 

2d. The blister on the left arm remains in an ulcerated state ; 
that on the right is dressed for the first time. The epidermis is 
removed, and a round shield of blotting-paper covered with blis- 
tering ointment is placed upon the wound. It is covered with 
a watch-glass. The left arm dressed with simple cerate. 

3d. Left arm. — Flesh granulations begin to appear on the base 
of the ulcer which is partly cleansed, and is now of a coppery-red 
color. The suppuration is still very considerable and disagreeable. 
Dressing, simple cerate. 

Right arm. — The blistered surface has copiously suppurated ; its 
surface is red, and the granulations not diminished. The watch- 
glass has produced a complete circular notch. Dressing of blis- 
tering ointment ; watch-glass no longer used. 

* The folio-wing was the diagnosis of M. Puche, in reference to the accidents on 
the patient that furnished the matter for inoculation. Indurated chancre on the 
edge of the prepuce for four or five months, treated by an apothecary and healed. 
Mucous tubercles on the scrotum of fifteen days' standing. Mucous tubercles at 
the margin of the anus. Roseola nearly effaced. Ulceration on the right pillar 
of the velum palati. Rheumatic pains. Xo other symptoms. The pus for inoc- 
ulation was taken from clusters about the anus. 



MUCOUS TUBERCLE. 273 

August 4th. Left arm. — The fleshy granulations have multiplied. 
The base of the wound is now on a level with its edges. The su- 
perior ulcer, caused by the watch-glass, does not yet seem inclined 
to cicatrize. Simple dressing. 

Right Arm.-. — The blistered surface is of a rose color, and is not 
depressed. The circular notch produced by the watch-glass is 
effaced and replaced by a superficial excoriation. Dressing, blis- 
tering ointment. 

Aug. 5th. Left Arm. — The ulceration is replaced by a red layer, 
from two-fifths to four-fifths of a line in height, surface of a cop- 
pery red, and irregular. The circumference of this layer is quite 
limited and not hard. All around it, that portion of the blistered 
surface which has not been in contact with the specific dressing is 
red, without granulations, and covered with thin crusts formed by 
concrete pus. The wound produced by the watch-glass healed 
without granulating. The suppuration is somewhat less but 
always fetid. On wiping the wound with linen, it produced but a 
slight bleeding. Dressing of simple cerate. 

Right Arm. — The wound presents the same aspect; it is of a 
rosy color, granulated, and not ulcerated. Dressing with the blis- 
tering ointment. 

Aug. 6th. Both blisters dressed with the cerate. 

9th. Left Arm. — The notch made by the watch-glass has healed. 
The diameter of the fungous growth is somewhat less, and it still 
projects from two-fifths to four-fifths of a line above the level of 
the surrounding parts. It is circumscribed by a reddish-brown 
circle, and its surface always presents the same irregularity, soft- 
ness to the touch, still furnishing a little pus somewhat less odorifer- 
ous. Simple dressing. 

Right Arm. — Nothing special. Cicatrization has commenced. 

Aug. 11th. Left Arm. — The wound is as large as a franc piece, 
and distinctly circumscribed. The granulations covering it are 
united together in such a manner that the surface is less unequal ; 
it is of a pale red and somewhat copper colored, soft to the touch, 
and a little bloody when chafed by the linen. The suppuration, 
however, is now small in quantity ; it still has an odor. Simple 
dressing. 

Right Arm. — Completely cicatrized. No dressing. 

Aug. 23d. The left arm has been dressed every -morning during 
the visit of M. Vidal. The cluster has not changed its aspect ; it 
is always about four lines in diameter, rising above the level of the 
surrounding tissues which have resumed their natural color. The 
surface is covered with soft fungous growths, not bloodjr, of a yel- 
low color, and furnishes a certain quantity of pus. 

27th. No change. 

29th. There is an inflammation which appears as if inflated. 
Above this is an ulceration which is hollowed . on a rose-colored 
protuberance, covered with a cicatrix thin and transparent, which 
has been produced in the twenty -four hours 

30th. The rose-colored tubercle, in the centre of which the 
wound existed, has disappeared. The ulceration is now on a level 

18 



274 VIDAL ON VENEREAL DISEASES. 

■with, the surface of the skin ; it is superficial, of a yellow color, 
and always of the same extent. 

The patient left the hospital. Nothing on the penis. The muc- 
ous tubercles about the anus are dry and have almost entirely 
disappeared. No eruption on the skin. During his stay in the 
hospital discovered no roseola. 

In the second week of September, the patient, who resided at 
Versailles, came to see us. He exhibited the arm inoculated, and 
in the centre of the blister we found an elevation, resembling a 
waistcoat button. It was dry, and of firmer consistence than the 
tumefactions which we have already observed at the same place ; 
in fine, it resembled certain mucous tubercles that form on the skin 
of persons of dark complexion. 

Such is the case as reported by M. Pellagot. 

It may be objected, that, in this case, the blister on the left arm, 
was but the exciting cause of the accidents observed on that limb, 
as the subject inoculated was fully infected with syphilis, and had 
mucous tubercles at the anus. But why did not the second blister, 
that on the right arm, produce the same effects ? 

An ulcer, with a yellowish base, followed the active inflammation 
of the inoculated blister, and on this base a papule was developed. 
It may be urged that this ulceration was a chancre, and the papule 
a transformation of this chancre, which remained susceptible of the 
change. At first, the glands, in the vicinity of the points inocu- 
lated, were not enlarged. I am perfectly aware that we may have 
a chancre without a bubo, and yet I note this circumstance. Fur- 
ther, it is of but little consequence whether this was a chancre or 
some other form of ulceration, for I do not pretend by inoculation 
to reproduce the same form of lesion as that which furnished the 
matter for the purpose. This is not the question ; but the prob- 
lem is, to know whether a syphilitic affection can be communi- 
cated by the product of papular eruptions. Some may go so far 
as to say that I took the matter from a chancre, instead of a papu- 
lar eruption. To this, I reply, that Mr. Puche made the diagnosis 
impartially. 

These facts leave no longer room for doubt : the mucous tu- 
bercle may be inoculated and is contagious. I have already stated 
that M. Ricord stands almost alone in denying its contagiousness. 
But even by his own words, we may compel him to acknowledge 
the contrary. Indeed, at page 182 of his Traite pratique des mala- 
dies veneriennes, we find these words which I transcribe : " But 
contagious by some incomprehensible vital action, and which cannot 
be explained, the mucous tubercle cannot be transmitted by inocu- 
lation." Thus, M. Kicord is evidently a contagionist, and he makes 
a distinction between physiological inoculation, which is contagion, 
and experimental inoculation. The latter only he rejects. MM. 
Baumes, Reynard (of Toulon) and other writers on syphilis who 
regard the mucous tubercle as contagious, do not admit its trans- 
missibility by inoculation. In a practical point of view, this re- 
jection is of no importance if we admit its contagiousness. Bui 
it is probable that if the writers on syphilis who deny the second 



MUCOUS TUBERCLE. 275 

mode of propagation, had adopted the proceedings of Wallace ; if 
they had repeated to a sufficient extent his experiments ; if they 
had not formed their conclusions until the required period of in- 
cubation had passed, a very long time when secondary accidents 
are inoculated ; if these writers had properly performed their ex- 
periments, they would have observed results analogous to those 
witnessed by Wallace, M. Bouley and all those who are aware 
that the circumstances are different in the case of inoculation with 
the matter of secondary accidents, from those which attend the 
same proceeding with that from primary accidents. 

Treatment. — Regarding the mucous tubercle as a consecutive 
syphilitic accident, it may be stated that it is one which soonest 
appears and disappears. Eest and cleanliness are often sufficient 
to cause its disappearance from the genital organs and the anus, 
and this, too, in the course of twenty days, especially when they 
are not of long standing, nor complicated. 

Patients in my service affected with tubercles about the anus or 
the genital organs, take a hip-bath daily, except on the day of 
using the general bath. By these repeated washings, and rest in 
bed, the tubercles shrink, and rapidly disappear. M. Baumes 
adds from one to three drachms of corrosive sublimate to the hip- 
bath. He applies a lotion of pure chloride of sodium, if the tuber- 
cles are not ulcerated and surrounded by an inflammatory areola. 
When these complications exist, it is better to dilute the chloride 
with a certain quantity of water, so that it may produce only a 
slight smarting sensation, and not a real pain. 

The following is the formula of M. Baumes : 

^ . Chlor. Calc. vel Sod. § vi. 
Aq. dist. 3 xvi. 

This solution may be changed for that of the acetate of lead, 
sulphate of alumina and potash. Some practitioners prefer corrosive 
sublimate. From three to fifteen grains may be dissolved in two 
ounces of water, according to the susceptibility and irritability of 
the parts. We have then in view not only the local treatment, 
but a certain influence on the diathesis, which I believe to be an 
illusion. The nitrate of silver is the substance that should be pre- 
ferred. It not only hastens reparation, but it is the agent which 
most promptly subdues the pain, relieves the smarting sensations, 
and the pruritus with which the patient is harassed during the 
night. The tubercles about the anus and perineum, which are 
more or less liberated, and the secretion of which inflames the sur- 
rounding skin, are those which produce the greatest suffering 
Relief is afforded by the following application : 

Ij& . Nit. Argent. 3 iss. 
Aq. dist. § iiiss. 

This may be repeated every three days, until the tubercles are 
evidently modified. 



276 TIDAL ON VENEREAL DISEASES. 

After each cauterization, the hip-bath is to be used, and the 
parts should be washed with a decoction of poppy-heads, or a 
dilute solution of opium. They may also be touched with a 
crayon of the nitrate of silver, especially when we wish to limit 
the action of the caustic, as in cases of superficial ulcerations, or 
if the tubercles assume the form of condyloma ; we may then, by 
cauterizing a little more thoroughly, gradually destroy the excres- 
cence, to the extirpation of which by the knife the patient may be 
opposed. The crayon is especially to be preferred in treating 
those tubercles which grow in cavities or on the uterine neck. 
Those in other regions may be sprinkled with some inert powder, 
such as amidon, or calomel (d la vapeur). 

I have never been an advocate for the use of ointments, either 
of mercury, the oxide of zinc, or of the iodide of sulphur. I have 
always found that their application only irritates the parts. Some 
practitioners employ them after the cure of the tubercles, in order 
to remove the stains that are left behind. 

M. Baumes places a high value on the following ointment : 

^. Calomel, 3 iiss. 
Axung. 3 yiss. 

At the commencement of my remarks on the treatment of the 
mucous tubercle, I stated that this accident is one that most 
readily disappears, either from cleanliness or from the treatment 
which I have already mentioned. I should also add, that it is 
one of the accidents that most frequently returns, and that is most 
speedily and surely reproduced, either under the same or some 
other form, when the above measures only are adopted. "We 
should, therefore, administer a general mercurial treatment, which 
should be commenced at the same time with the local, or after 
some days of repose, especially if there be marked irritation, or 
inflammation. The latter is the course which I generally pursue. 
In the case of inflammatory complications, when the subject is 
young, I begin with blood-letting from the arm ; this depletion is 
employed for the double purpose of subduing the inflammation, 
and of preparing the way for the action of the mercury. 

M. Baumes recommends the corrosive sublimate according to 
the formula of Yan Swieten, or in pills. I prefer the proto-iodide, 
which I administer as stated in speaking of the treatment of con- 
firmed syphilis. I give the pills, when the tubercles exist with 
other accidents which show that the syphilitic diathesis is estab- 
lished. On the other hand, when we have reason to regard the 
tubercles as primary, the corrosive sublimate should be preferred. 



PART SECOND, 

CONSECUTIVE VENEREAL DISEASE (VEROLE). 



The diseases which form the subject ot our present investiga- 
tions have been called consecutive, because they generally follow 
those considered in the previous section, and because the syphilitic 
virus has so acted on both the fluids and the solids as to create a 
special constitution, for which reason these consecutive affections 
are also called constitutional; writers also speak of a, syphilitic diath- 
esis or confirmed verole, or simply the verole. 

I shall treat of these diseases in two different chapters. In the 
first, I shall consider them in general ; I shall thus pass in review 
their characters, the period and order of their appearance ; I shall 
inquire into the causes that produce them, and shall consider the 
syphilitic fever, and the state of the blood during the verole ; I 
shall afterwards discuss the question, whether it is possible to 
have syphilis more than once, and shall conclude with an import- 
ant chapter, viz., the treatment of syphilis. In the second chap- 
ter, I shall treat of consecutive venereal diseases in particular. 



CHAPTER I. 
GENERAL REMARKS. 



SECTION I. 
CHARACTERS. 



The title of this chapter indicates what I have already stated, 
that the diseases which we are now investigating appear after 
those which have been studied in the preceding section. But I 
have not been absolute, and by my reserve I wish to show myself 
faithful to the principles which I have advocated in considering 
the subject of physiological absorption, which is the introduction of 
the syphilitic virus into the system, without ulceration, and with- 
out previous inflammation of the surface to which it is applied. 



278 VIDAL ON VENEREAL DISEASES. 

Yiras absorbed by a sound surface may produce precisely the 
same effects upon the system as that which has given rise to the 
so-called primary accidents, the diseases of this second section 
may therefore be primary; they may appear at once (d'emblee), 
and be the first manifestations of syphilis. But they are com- 
monly observed after a longer or shorter interval from the first 
syphilitic impression ; they are apt to appear at several points, 
and in different regions at the same time, or successively, and may 
extend over a large surface ; on this account they are called gene- 
ral affections. The syphilida, which may be seen growing at all 
points of the cutaneous surface, present a remarkable example of 
this form of venereal disease. On the contrary, the lesions most 
frequently primary are generally confined to the narrow sphere of 
contagion, hence they are called local 

All the tissues may be invaded by syphilis, from the epidermis, 
the dermous and cellular, to the fibrous, osseous, and parenchyma- 
tous tissues. The lesions assume the most varied forms, from the 
simple pimple, to the largest sized tumor. Their color is of a 
reddish, coppery tinge, peculiar to the majority of these diseases; 
it is so characteristic, that it has been called the syphilitic tint. As 
a subjective symptom, nocturnal pains often exist; they are so 
inseparable from certain consecutive lesions, that their existence 
alone leads to the suspicion of syphilitic infection. Their progress 
is generally slow ; we do not observe those severe inflammations 
which attend the primary accidents. They are rather alterations, 
which are slowly destructive ; for obstinate ulceration seems to be 
the characteristic of syphilis when left to itself, and it infallibly 
produces this effect in bad constitutions, and where complications 
exist. If the influence of specific treatment in primitive venereal 
disease may be questioned, such is not the case here, for nature, in 
the majority of cases, is impotent, and simple measures are of no 
avail. On the contrary, in certain of the syphilida, the mercurial 
treatment, and in certain tumors the iodides of potassium, exert 
sometimes so prompt, so direct an influence, that it is impossible 
to deny their efficacy- But even here, we should not exaggerate 
the power of therapeutical agents, and undervalue that of the vix 
medicatrix natural, which alone may cure the worst cases, when 
heroic means have failed. We will only observe, that such are 
very exceptional cases. 

section n. 

PERIOD, AND ORDER OF APPEARANCE. 

"When several consecutive accidents occur, they generally appear 
at different epochs. This fact has been noticed by every observer. 
It has even been assumed, that they appear in a certain order. 
But these periods have not been definitely fixed, and this order, 
as is proved by observation, is not completely regular. 

According to Hunter, the period at which consecutive accidents 
appear, varies according to the susceptibilities of the parts in- 



PERIOD, AND ORDER OF APPEARANCE. 279 

volved. In this point of view, there are parts of the first order and 
parts of the second order. Those of the first order, that is, the most 
snsceptible, are the skin, tonsils, nose, throat, internal surface of 
the month, and sometimes the tongue ; in other words, the skin 
and certain mucous membranes. Those of the second order are 
the periosteum, the aponeuroses, and the bones. Hunter attrib- 
uted great influence to the air as a determining cause of constitu- 
tional affections, believing, as he did, that the morbid action was 
exerted more directly on the integuments, in consequence of the 
contact of the air producing there a greater susceptibility. Ap- 
plying the same theory to the evolution of diseases affecting the 
second order of parts, Hunter showed that the parts of the skele- 
ton nearest to the skin, were affected before the deeper seated 
bones ; thus the bones of the head, the tibia, the ulna, the ossa 
nasi, become more frequently and more quickly affected than 
those of other parts. He also supposed that the susceptibility 
might depend on the structure of the bones ; it therefore depended 
both on the proximity of the skin and the hardness of the osseous 
tissue. Hunter, moreover, acknowledged that this order might he 
inverted, and he admitted the possibility of the lesion of the parts 
of the second order, the first having never been affected, that is to 
say, Hunter having a mind eminently disposed to generalize, lost 
no opportunity of so doing ; but as he was at the same time a 
profound observer, the exceptions did not escape him, as he was 
sometimes sufficiently candid to acknowledge. Hunter, besides, 
never spoke of immutable laws, as he was too well acquainted with 
the nature of disease ; he was well aware, that it is particularly 
during the existence of disease that laws are not constant. 

Thus in adopting the philosophic views of Hunter, and receiving 
his theory at its proper value, we may admit and sanction, to a 
certain extent, the two orders of lesions he established, and "this 
too from undoubted analogies and proof the most direct. Indeed, 
when the syphilitic virus is applied to the living tissues, every 
part does not react equally against it, or rather, is not similarly 
affected at the same time. The integuments, as a general rule, 
are the first affected, or furnish the first manifestations of the im- 
pression they have received. This is not peculiar to the syphilitic 
virus ; all morbid agents of this class produce analogous effects ; 
indeed, the virus of rubeola and of variola manifest their first 
effects on the skin by exanthematous and pustular eruptions, 
which are irritated by the syphilida ; for the rubeola and the 
variola are repeated by roseola and a certain form of ecthyma. The 
parts belonging to the second order, according to Hunter, are the 
fibrous and osseous tissues of a much lower grade of action and 
vitality than the skin and mucous membranes ; consequently, when 
morbid changes occur it is only after they have manifested them- 
selves on the integuments. The skin, besides, being exposed to 
view, its slightest changes of color and stains are seen even from 
the commencement, whilst analogous phenomena, passing in the 
subcutaneous tissues, the periosteum and bones, cannot be known, 
for there the lesions become appreciable only after a tumor has 



250 VTDAL OX VENEREAL DISEASES. 

formed, when in fact they have existed for a much longer period. 
Thus, whatever view be taken of the matter, it will be seen that 
the cutaneous affections must be observed, before those more 
deeply seated. This has been noticed by the most simple ob- 
servers, but those who know how to interrogate nature completely, 
will admit it as a general though not an absolute rule. M. Eicord 
adopts the division of Hunter, and denominates the diseases which 
affect the parts belonging to the first order, secondary accidents, 
and those of the second, tertiary accidents, because he places at the 
head primary accidents. Syphilis may therefore be completely 
embraced in the following summary : 

1st, Primary Accidents. 

2d, Secondary Accidents. 
3d, Tertiary Accidents. 

This division is an old triade ; for we find it complete in Thierry 
de Hery, and it has been traditionally handed down by every 
writer who has followed him." M. Ricord has rejuvinated it, has 
rendered it popular, by descending from his high philosophical 
position, and by representing it as based on experiment. This, 
too, has been done at a time when this method was much in vogue, 
and it has been represented as being capable of simplifying the study 
of syphilitic diseases. It is, therefore, greatly admired by certain 
minds, which are satisfied with a superficial investigation of mat- 
ters, and which have not the time to sift them to the bottom. 
Those, however, who like a thorough investigation, discover in 
this classification, serious and very grave objections. But as 
most of its opponents were not convinced of the utility of resort- 
ing to experiment, as they believed in its dangers and judged it 
immoral, they are disposed to neglect and even censure this means 
of popularity ; hence their little success compared with those who 
attach so much importance to this method of investigation. How- 
ever, among these opponents, there are some, who relying chiefly 
on observation, still know the value of experiment, and believe 
that when employed within certain limits, it may be advan- 
tageous to science, and that it does not violate the laws of morality 
properly interpreted. They therefore experiment more philo- 
sophically ; that is, without losing sight of observation, and not 
satisfied in addressing the mind alone, they speak also to the 
senses, and it was especially by means of experiments, that they 

* " Thierry de Hery. La Methode curatoire de la maladie venerienne, p. 133. Several 
symptoms or accidents are common to this disease, some of which precede, others 
follow, and others again supervene on these. Those which precede are ulcers of 
different kinds : ardor urina>, buboes, which being said to precede, though they 
may be equivocal, and may or may not arise from contagion, do, nevertheless, 
most generally precede, and may serve as precursors of the disease. The others, 
which we call consecutive, are pustules and ulcers on all parts of the body, princi- 
pally on the private parts, the fundament, the mouth, the throat, the forehead, and 
the emunctories. In like manner, there is also a falling off of the hair commonly 
called peloda, articular pains, often also wandering, but seldom nodosities. 

"The latter which we call superadded or extraordinary, which appear after im- 
perfect cures, &c, &c, <fec. 






PERIOD, AND ORDER OF APPEARANCE. 281 

successfully attacked the errors of this method. In speaking of 
mucous tubercles, I have already shown their inoculability, a fact 
which had been denied by the advocates of experiment, that is, of 
partial experiment: we shall soon meet with remnants of the 
errors of this same experimental method. I commence with the 
classification.* 

1st. Primary Accidents. — There is but one, viz., chancre, which 
once cured, cannot be reproduced unless by fresh contagion. It 
may be inoculated but cannot be transmitted hereditarily. 

A. It has already been demonstrated in this work (first sec- 
tion), that there is a virulent blennorrhagia ; chancre, therefore, 
is not the only primary accident. B. It is very true that chancre 
may be inoculated, readily inoculated ; but it must be added that 
it cannot always be inoculated. 

2d. Secondary Accidents. — These embrace certain cutaneous 
eruptions, as well as certain affections of the mucous membranes, 
and their dependencies, and particular morbid conditions of the 
eye, and lymphatic glands. These accidents, without being in- 
oculable, can be transmitted only hereditarily ; they seldom occur 
before the third week after the primary accidents, and still more 
rarely after the sixth month. 

As to the transmissibility of the secondary accidents, aside from 
hereditary descent, the doctrine is proved by the fact of the in- 
fection of the nurse by the child affected with consecutive tubercles, 
and the contagiousness of the mucous tubercle in the adult ; it has 
been proved by the experiments of M. Cazenave, Wallace, Waller, 
M. Bouley, M. Eichett, M. Litthmann, by my own, and by those 
of other experimenters. Under the head of mucous tubercles ex- 
periments have already been mentioned, and when we come to 
treat of the pustular syphilida, we shall find certain facts which 
leave no doubt on the subject. The distinction, therefore, between 
the primary and secondary accidents, which rests on their trans- 
missibility, a distinction to which so much importance has been 
attached, is destroyed both by experiment and clinical observation. 
Both primary and secondary accidents are inoculable. 

B. With reference to the time of the appearance of secondary 
accidents, it has been stated, that as a general rule, it is seldom 
before the third week, and rarely after the sixth month. This, 
nevertheless, is not true, at least according to those observers who 
have devoted especial attention to the subject. Thus, MM. Legen- 
dre, Martins, and Cazenave, have fixed upon a medium far above 
the maximum time laid down by M. Eicord. M. Legendre, one 
of the most distinguished pupils at the San Louis, author of a re- 
markable thesis on the syphilitic eruptions, thus remarks : "I have 
obtained, as a general medium, from the time of the appearance of 
the primary to that of the secondary accidents, (syphilida,) five 
years, precisely the same result as that mentioned by M. Martins 
in his Memoir." 

3d. Tertiary Accidents. — These consist in special alterations of 

* The propositions are numbered ; the objections are indicated by the letters. 



282 VEDAL ON VENEREAL DISEASES. 

the sub-cutaneous cellular tissue, of the testicles, and the fibrous 
and osseous tissues of the deeper seated organs. These accidents 
cannot be inoculated, neither can they be transmitted hereditarily 
with their peculiar physiognomy ; yet, by a kind of degeneration 
or modification of syphilis, they may become one of the most fruit- 
ful sources of scrofula. 

A. I shall be guarded in my remarks on thesepoints. It will be 
necessary, moreover, to consider these questions again in our remarks 
on infantile syphilis. I will say, however, in advance, that this doc- 
trine of the transformation of one disease into another, especially 
into the formation of a diathesis, is an ancient one, and that there 
are but few arguments in its support. B. M. Eicord observes that 
tertiary accidents never appear before the sixth month, and may 
manifest themselves several years after the appearance of the pri- 
mary accidents. To this I would reply, that I have seen cases of 
periostosis at a much earlier period, even during the existence of, 
the primary accidents, and long before the sixth month. Besides, 
it may appear d'emblee, that is, as the first manifestation of syphilis. 

In conclusion we would remark, that the division into three 
orders, based on their transmissibility or non-transmissibility, is only 
arbitrary, and that the period of their manifestation is not perfectly 
defined. The fact, moreover, even though it be exceptional, 
of the actual occurrence of both the secondary and tertiary accidents 
d'emblee, destroys the value of any character derived from the inter- 
val of the primary and the other accidents, since the pox may 
consist simply of a syphilitic eruption or an exostosis, without any 
other preceding syphilitic affection. 

It should also be known that the three divisions above mentioned 
cannot represent all the distinct accidents, all the phases of syphilis. 
Thus, after chancre, sometimes long after its cure, a really syphilitic 
bubo may appear, which cannot strictly be considered as a primary 
accident, since it has been preceded by another accident. It is 
denied a place among the secondary accidents, since it is inocula- 
ble, and the doctrine is, the non-inoculability of secondary acci- 
dents. A successive accident has therefore been established. But 
as the same accident, the same bubo, may exist without a preceding 
chancre, d'emblee, it is therefore sometimes primary, sometimes sue* 
cessive ! Now, examine carefully the different accidents belonging 
to the third category, and it will be found that from the special 
affection of the sub-cutaneous or sub-mucous tissue, this kind of 
tubercular cutaneous disease, to the appearance of an exostosis, a 
very long time, even years may pass. These tubercles are fre- 
quently even nearer the secondary than the tertiary accidents. 
They have been called the accidents of transition. Thus, we have 
two orders of accidents, the successive and those of transition, which 
altogether raises to five, the number of orders of syphilitic acci- 
dents, or, if disposed to admit them only as fractions of accidents, 
perhaps this number will not be maintained ; but, in either case 
the triade will be compromised, for it is necessary to fix on some 
definite terms. It must not be supposed that these phenomena 
are always developed in the same manner, having the same relations 



EXCITING CAUSES. 283 

in the three great divisions ; they will be found, on the contrary, 
to change according to the requirements of the system. Then 
comes the inversion, that is, the appearance- in the last place, of an 
accident that passes for secondary, as in the case of 'certain of the 
serpiginous syphilida, which occur after an exostosis. I have 
already stated, that Hunter alluded to this inversion, and that 
Thierry de Hery placed these serpiginous ulcerations among the 
lesions of the third category ; he called them wandering (canibu- 
latifs) ulcers. 

I do not state these numerous objections for the mere pleasure 
of the act, but to render the young practitioner familiar with the 
exceptions, especially since they are so numerous and important, 
and to show that what appears very simple when seen from a dis- 
tance and in the schools, may in reality be very complex when 
closely examined, and in the presence of nature. In the majority 
of cases, indeed, the cutaneous venereal disease does follow next in 
order to the primary accidents ; then come the sub-cutaneous affec- 
tions. In both orders the highest forms are first observed ; the 
period passed in incubation, in relapses, tends to aggravate the 
lesions which are about to appear. Thus we see the cutaneous 
lesions assume at first the light and superficial form of the exan- 
themata, and after awhile, sometimes after repeated relapses, reach 
the state of the perforating tubercular syphilitic eruptions. As to 
the sub-cutaneous lesions, we observe the cellular, then after awhile 
the fibrous and osseous tissues attacked, and finally the viscera 
become invaded, and the diathesis after a time passes into a state 
of cachexia. Such is the general course of events, but this is not 
always the case, a fact which should be carefully remembered if 
we desire the truth, and would avoid deception. 



SECTION III. 

EXCITING CAUSES. 

I have already stated that the syphilitic virus may remain a 
cause without effect, and that the diathesis may not be established, 
by the simple absorption of this agent. Other causes are required 
to develop this diathesis. These have been sought for in the 
idiosyncrasy, sex, age, temperament, hygienic and pathological 
conditions. 

It is evident that every subject is not equally favorable to the 
development of the diathesis ; some there are, who are completely 
refractory to its influence. In them, the virus, when introduced 
into the system, remains always in an inocuous state, or rather 
it is destroyed and expelled in some unknown manner ; iudeed, 
well-marked chancres in certain subjects, when left to themselves, 
or treated by very mild and insignificant means, have been radi- 
cally cured ; in other words, the reparation of the ulcer has been 
complete, and nothing of a syphilitic character has been observed 
to follow in these patients. The advocates of the physiological 



284 YEDAL OX VENEREAL DISEASES. 

doctrine, those who deny the existence of a virus, and whose 
treatment corresponds with such an opening, have published 
numerous facts, to show that the virus in its effects may be limited 
to the production of the primary accidents. This is a well-known 
fact. But we do not know the influence of age, constitution, tem- 
perament, sex, which can most frequently assure us of this im- 
munity. It has been supposed that strumous constitutions were 
most favorable to the development of the consecutive accidents. 
Facts have proved only, that under such circumstances, syphilis 
produces its greatest ravages, and nothing more. "We must also 
take into account the fact that very numerous cases have occurred 
to prove that most excellent constitutions have equally suffered 
from syphilis as have those the most deteriorated. As to the in- 
fluence of sex, I can only say, that at the Lour cine, in the female 
service, comparatively speaking I have less frequently observed 
cases of confirmed syphilis than at the Hopital du Midi, where only 
males are now treated. This I speak from memory, as I have no 
statistics by which to establish the influence of sex in the produc- 
tion of consecutive accidents. But it is generally admitted, that 
in the female, syphilis is less grave than in the mala As to age, 
it may be observed, that during infancy, syphilis being hereditary, 
we find only the so-called secondary accidents ; these are generally 
pustules, bulla, and seldom erosions, in which case the disease is 
very severe. As we pass from infancy, constitutional syphilis is 
less common. In the adult, consecutive affections become again 
more frequent and aggravated. These accidents, then, are not 
only attended with greater danger, but the graver are more fre- 
quent than the lighter forms of the disease. 

There are hygienic circumstances, and others which may be 
called pathological, which exert a real influence on the production 
of consecutive accidents. Thus, inadequate nourishment, exces- 
sive indulgence at the table, excessive fatigue, a sudden change of 
temperature, may exert a powerful influence on the development 
of constitutional syphilis and its relapses. It has been known to 
appear after going from a warm to a colder or more humid climate, 
and cures been known to follow the opposite change. The influ- 
ence of temperature, however, on the production of consecutive 
symptoms, should not be exaggerated, for facts show that both 
cold and heat may in turn prove an exciting cause ; thus I have 
observed the case of a blacksmith who had syphilitic eruptions 
only on the fore-arm, the hands, and parts most exposed to the 
fire of the forge. Carelessness, want of cleanliness, and misery, 
seem favorable to the development of certain accidents ; this we 
may daily find illustrated among the unfortunate workmen 
who enter the Hopital du Midi, covered with mucous tubercles, 
and who obtain prompt relief by simple repose, arid local and 
general bathing. 

As to the pathological circumstances, syphilitic eruptions have 
been seen to follow an attack of fever. But who knows that this 
was not a syphilitic eruptive fever ? A syphilide has really been 



SYPHILITIC FEVER. 285 

seen to follow an inflammation of the abdomen, and the chest. 
However, on this point, that is, the influence of pathological cir- 
cumstances, writers on syphilis are less unanimous than on that 
of hygiene. 

SECTION IV. 

SYPHILITIC FEVER. 

This, strictly speaking, resembles that of the eruptive fevers, for 
it occasionally precedes the syphilida, and generally subsides when 
the eruption appears ; it also sometimes remains, or exists, in con- 
nection with some one of these symptoms. If fever consisted 
entirely in an acceleration of the pulse, surely there would be but 
very few syphilitic fevers, preceding or accompaning the consecu- 
tive accidents ; syphilitic fever, such as that observed by M. Cas- 
telneau,* and described by M. Chausit,f attends only the primary 
accidents. It is not that the blood is not profoundly altered when 
this fever follows the consecutive accidents, but it then has the 
chronic character which these accidents generally assume, and the 
troubles of hematosis are generally manifested by symptoms of 
chloro-anemia. 

The modifications of mobility and sensibility are less obscure. 
Thus before the appearance of certain syphilida, the patient com- 
plains of painful weariness, weakness, and loss of muscular power, 
precisely in the same manner as is observed when the eruption is 
about to appear in infantile syphilis. What is particularly well 
marked, are the changes, which have been compared to neuralgic 
or rheumatic pains. They are felt principally on the head, in the 
vicinity of the articulations, sometimes in the lumbar region ; they 
are the rheumatic pains of modern writers. They precede the 
appearance of the lightest forms of accidents, called secondary, 
and may likewise usher in those more deeply seated, and accom- 
panied with relapses. These rheumatoid pains are not constant, 
there being often a kind of intermission, and the paroxysms are 
excited by heat, especially when in bed. According to M. Eicord, 
the patients who thus make day of night, may invert the order of 
the attack of the paroxysm. This is not absolutely true. The 
.same writer has attempted to make a distinction between these 
pains and osteocopes, which belong to another stage of the disease. 
The rheumatoid pains are not at each paroxysm seated in the 
same place, and during the intermission, pressure does not repro- 
duce them ; on the contrary, some patients find relief by resorting 
to compression, at the moment when the paroxysm commences, 
and by moving the painful limb. Exposure of the limb to the 
action of cold, produces also the same happy effect. The color of 
the skin, and the temperature, remain unchanged, nor is there any 
tumefaction. The case is quite different when the pains depend 
upon profound lesions of the bone. 

* Vide Annates des maladies de la peau et de la syphilis, t. ii. 
f Vide the same journal for April, 1852. 



286 VIDAL ON VENEREAL DISEASES. 

Hunter alluded to the syphilitic fever, and those who are en- 
gaged in examining claims of priority, should know that this wri- 
ter first asserted that this fever strongly resembled the rheumatic 
fever.* In speaking afterwards of the constitutional symptoms, 
he speaks of pains like rheumatic pains.-\ But generally, Hunter 
regarded this fever as an accompaniment of the consecutive lesions 
and not as a forerunner of the disease. 

M. Eicord has attached great importance to the enlargement of 
the glands in the posterior cervical region, as the first indication of 
infection. This glandular enlargement, which is but a consecutive 
bubo, really occurs in the region mentioned ; but the same con- 
dition exists in every region where glands are found, and when 
sought for, may generally be detected. I will repeat, besides, 
what I stated in speaking of adenitis, which is regarded as the in- 
evitable companion of indurated chancre ; viz., the same tumors 
may be produced by the slightest ulceration, the least pimple on 
the skin ; and as they depend upon a strumous affection, and may 
be anterior to the syphilitic attack, their importance should not be 
over-estimated in forming a diagnosis. 



SECTION V. 

STATE OF THE BLOOD IN SYPHILIS. 

I have already proved, and shall again demonstrate, that certain 
morbid products, during an attack of syphilis, are inoculable ; as 
to the normal secretions, these will be considered when we come 
to treat of the causes of infantile syphilis. We shall find that 
syphilis may be inherited from the father, by a certain alteration 
of the semen. I shall also discuss the question, whether a nurse 
can by her milk infect the child. 

We are now to consider the state of the blood in syphilis. Ac- 
cording to Waller, the degldbulization of the blood during the syph- 
ilitic diathesis would seem partly probable, from the aspect of 
the patients, and certain other accidents from which they suffer ; 
but a demonstration based upon the analysis of the blood has not 
yet been made. Doctor Serch, at the request of Waller, subjected 
to a quantitive analysis, the blood of several venereal patients, 
without arriving at any positive results. M. Grassi, however, is 
said to have made analyses which showed that in the blood of sub- 
jects affected with consecutive acccidents, the proportion of glo- 
bules is diminished, and sometimes, in a very notable manner, the 
contrary obtains when the patients are under the influence of the 
primary accidents. The proportion of albumen was inversely to 
the quantity of the globules. This has led M. Dourvault, who has 
published the experiments of M. Grassi, to say: "In proportion 
as syphilis infects the system, the nutritive fluid gradually loses its 

* Hunter, by Babington, Am. ed. 
f Ibid., p. 559. 



STATE OF THE BLOOD W SYPHILIS. 287 

strength, by the resolution of its globules into albumina."* I can 
only say, that subjects laboring under primary symptoms are some- 
times very debilitated, and their blood is not rich in globules, whilst 
others whose systems are fully saturated, are plethoric. 

The question has been considerably agitated whether the virus 
is only mixed with the blood, its connection being only physical, 
and therefore its properties remaining unmodified, or whether its 
properties are modified and changed. According to "Waller, the 
idea of the simple mixture of the virus with the blood, is opposed 
to the principles of physiology, and experiment disproves it, by 
demonstrating that inoculation made with the blood is incapable 
of reproducing a primary chancre, whilst secondary syphilis may 
be thus communicated to sound subjects. Carmichael mentions 
two facts in confirmation of this ; and they are also corroborated 
by Waller. The latter physician* besides, has performed a most 
conclusive experiment, the details of which I will relate. Accord- 
ing to Hunter the blood possesses no contagious property. 
"Could a syphilitic inflammation be excited in a previously- 
healthy wound, no person in whose blood the venereal poison cir- 
culated, that is who had constitutional syphilis, could escape a 
venereal ulcer whenever he was bled or received the scratch of a 
pin ; the little wounds thus inflicted, would become transformed 
into so many chancres. Indeed, if the point of a pin or a lancet 
should be dipped in venereal pus, their punctures would become 
chancres.f Here is a doctrine, that lately has singularly obscured 
the question of the inoculability of secondary accidents. Hunter 
maintained that the virus combined with the blood, produced the 
same effects as the pus from a chancre ; of course, it would produce 
chancres on the patient himself. Such being the case, it follows 
that it would produce the same effect when inoculated on a sound 
person. "Waller has already responded to Hunter. Moreover, 
the question should be differently framed. It should be not 
whether the blood may transmit such or such a form of syphilis, 
but whether it can transmit syphilis under any of its forms. If 
not thus enlarged, it amounts to nothing. 

Those who deny the possibility of transmitting anything by the 
blood, base their belief upon the facts showing that wounds on 
patients whose system is completely contaminated with syphilis, 
have been seen to heal like those on sound subjects, and on the 
immediate union which has followed after certain operations per- 
formed on persons infected with syphilis. This only proves that 
blood which, to a certain extent, has been changed, or which is 
mixed with a morbid poison, may supply the means necessary to 
cicatrization. This, moreover, had already been proved by the 
very numerous cases of union by the first intention, after the ex- 
tirpation of a tumor, and during the existence o£ a decided cancer- 
ous diathesis : as, for example, after the palliative operations for 
cancer, when there can be no doubt as to the alteration of the 



* Gazette Medicate, 1850, p. 200. 

f Hunter, by Babington, Am. ed., p. 21 



288 YIDAL ON VENEREAL DISEASES. 

blood. But these facts, furnished by pathology, and which I once 
undervalued, do not prove that the blood of a syphilitic subject 
cannot, under any circumstances, act even upon the individual 
himself, and produce syphilitic accidents in a certain order, and 
that this same blood may not be the vehicle of the poison, in trans- 
mitting the latter to the foetus, through the mother. No one has 
ever denied the first ; the second, which Hunter seems to reject, 
is now proved by carefully-observed facts : thus, the mother's 
blood is the medium of communicating to the child, to another 
being, the syphilitic poison. Both analogy and facts afterwards 
lent their aid to prove that syphilis may be transmitted by inocu- 
lating a sound person with the blood of one diseased. M. Diday, 
who, among the first in France, started the question of transmit- 
ting syphilis by other humors than the pus of chancre, speaks of 
the inoculations of glanders, of carbuncle, and of hydrophobia. 

" Nothing," he observes, " goes to prove that the blood of a 
syphilitic subject, when inoculated on a sound person, will not 
communicate to the latter the disease." Beturning to the proofs 
furnished by Hunter of the non-transmissibility by the blood, in a 
note M. Diday adds : " Hunter's argument proves but this, that he 
has here confounded the primary chancre with constitutional 
syphilis. Because the blood does not produce the former, is it 
right to infer a priori that it cannot produce the latter ?"* I have 
already mentioned that Waller is in the possession of two facts of 
contagion from the blood, and that he has made an experiment 
which has not been answered ; here it is : 

" Experiment with the blood of an individual affected with secondar^ 
syphilis. — F., a lad, set. 15, entered No. 5676, in infancy, had been 
troubled with the rickets, and, for the last seven years, had been 
affected with lupus exfoliatives on the right cheek and beneath the 
chin ; this lupus, of the diameter of a little more than half a dollar 
(American) piece, with the exception of a small space on the cheek, 
had been cured, after long treatment, by cauterization and the 
hydriodate of potassa. This lad had never had syphilis, and, 
being a proper subject for inoculation, it was performed on the 
27th July, 1850, on the left thigh. I took the blood from a 
female (Frennd), in whom secondary syphilis had been developed 
under our observation. This young girl, in other respects in most 
excellent health, had lately several times contracted primary sores, 
without having ever been affected with secondary sj^philis. But 
during the treatment of the two last chancres, which succeeded 
each other after a fourteen days' interval, she became emaciated 
and pale, and, when the last chancre was healed, and there re- 
mained only a uterine catarrh, tubercles appeared on the face, and 
spots on the surface of the whole body. 

" The inoculation w T as made in the following manner; the skin 
was scarified with a new scalpel, and ; by means of a cupping glass, 
from three to four drachms of blood were abstracted. Notwith- 

* Extract from the Gazette ledicale, Sept. 29th, 1849, first article on Prophylaxia, 
by M. Diday. 



It 

y 

: 



STATE OF THE BLOOD EST SYPHILIS. 289 

standing the rapidity with which the latter was done, the blood 
was still partly coagulated before it could be carried from the 
patient's chamber to that of the person to be inoculated. The 
wounds from the operation (performed on the child as in the pre- 
ceding experiment)* were carefully cleansed and cleared of the 
bloody clots by warm water ; the blood for the inoculation was 
then inserted into these wounds, partly by means of a small piece 
of wood, and partly by charpie saturated with the blood, which 
was applied and secured on the scarified parts. Neither inflamma- 
tion nor suppuration followed ; at the end of three days the wounds 
were completely closed. The patient continued well. 

11 On the 31st August, thirty -four days after the inoculation, I 
observed on the left thigh, at the point of inoculation, two distinct 
tubercles, of the diameter of a pea, of a pale reddish tint, dry on 
their surface, and attended with neither itching nor pain. In a 
few days they increased in size, became united at their base, and 
covered with scales, and both were surrounded by a dull red areola. 
The base of the tubercles, that is, the subjacent skin, and sub- 
cutaneous cellular tissue, became firm, tense, and an ulceration 
formed on the surface of the tubercles, which became covered with 
a thin and brown crust. In this manner, about the 15th Septem- 
ber, an ulcer had formed, the diameter of which equalled that of a 
pigeon's egg, a coppery-red areola surrounded its borders, and it 
was covered with the crust above mentioned. This crust having 
been removed, the base of the ulcer became visible ; it was of a 
funnel-shape, lardaceous, and bled easily at its edges. For some 
days previously an isolated tubercle had appeared on the right 
shoulder, as large as a pea, of a red color, and covered with thin 
scales. The patient could not tell the time of the first appearance 
of this accident. The general health remained good. 

" On the 26th Sept., and the two following days, F. complained of 
a want of appetite, and sleeplessness. On the 1st of Oct., sixty- 
five days after inoculation, and thirty-two from the appearance of 
the first tubercles, an exanthematous eruption was observed in 
the lower part of the abdomen, on the back, chest, and thighs ; 
this we pronounced a well-marked syphilitic roseola. The spots 
were precisely like those above described (in the first experiment), 
only at certain points they were somewhat more elevated. The 
ulcer on the thigh had acquired the breadth of a thaler (little 
more than the American half dollar), and still preserved its funnel 
shape, its lardaceous base, and coppery edge. A few days after- 
wards these spots became so numerous, that the entire body, not 
even the face excepted, was covered and appeared speckled. There 
was neither itching nor pain, nor symptoms of catarrh, nor fever. 
On the 6th Oct. several spots, particularly on the inner aspect of 
the thighs and on the abdomen, became raised into pimples or 
tubercles, and thence the diagnosis of the eruption, even without 

* Waller alludes to the experiment mentioned at the end of the first section, 
■whilst treating of the mucous tubercle. Small wounds were made with the scari- 
fier. 

19 



290 VIDAL ON VENEREAL DISEASES. 

knowing the antecedents, was attended with as little difficulty as 
in the preceding case * 

It will have been remarked that the wounds were covered with 
charpie saturated with blood, and that this dressing was secured. 
The wounds were therefore removed 'from the influence of every 
other contagion. Moreover, the period of incubation was so long 
that no one could for a moment suppose the intervention of the pus 
from a chancre, for it is known that after the inoculation of this pus, 
the local phenomena are not slow in their manifestations. M. Eicord 
maintains that there is then never a period of incubation. 



SECTION" VI. 

CAN A PERSON HAVE SYPHILIS MORE THAN ONCE ? 

It has been pretended that the consecutive accidents express 
the true syphilitic diathesis, and cannot be repeated in the same 
individual, or more strictly speaking, that a person can have syph- 
ilis but once in his life, thus assimilating this disease with variola 
and rubeola, which ordinarily occur but once in the same individ- 
ual. Thus far, this law which it is attempted to establish, has 
been based on mere assertions, and on analogical proofs. Now on 
this point, above all others, statistics are required. But it is diffi- 
cult to find cases so complete that we may know that the syphilitic 
diathesis is exhausted, that it has produced all which it can produce, 
What is still more difficult, is, to collect under one head, a suffi- 
cient number of cases to form statistics, the result of which may 
be erected into a pathological law having a real value. The diffi- 
culties, we may add the impossibitities of such an undertaking, 
arise from the duration of syphilis, the modifications and even the 
suppression of certain of its manifestations by treatment, and 
finally from its relapses. Typhoid fever, variola, rubeola, and 
other diseases which are supposed to resemble syphilis, f are of an 
acute nature, and continue but for a very short period ; a large 
part of mankind therefore remain liable to repetitions, which we 
may expect, and appreciate. On the other hand, in order that 
syphilis may have spent its full force, a considerable length of 
time is almost always required. The three stages characterized 
by the accidents called primary, secondary, and tertiary, have a very 
unequal duration, but as a general rule it is long. The length of 
the interval between the appearance of each accident varies also, 
and it is in general considerable. Take into calculation the num- 
ber of days, and sometimes of months, required for the reparation 
of a chancre ; note the months which intervene between the latter 
and the syphilida, and the duration of the cutaneous affections ; 
remember also the lesions of the parts beneath the integuments, 

* Waller, Du caractere contagieux de la syphilis secondairc, translated into French 
by M. Axenfeld, in 3 vols, of the Annates de lapeau et de la syphilis. 

If The uncist have finished with the discovery that we can have hydrophobia 
but once. 



CAN A PERSON HAVE SYPHILIS MORE THAN ONCE? 291 

the glandular engorgements, the tumors of the cellular tissue, nodes, 
parenchymatous affections, like those of the testicle ; add to this 
the time required before the fibrous and the osseous tissues may 
be invaded, and the gummy tumors, the exostoses show them- 
selves with all their characters, that the patient may have what 
are called tertiary symptoms, and the really tertiary symptoms ; 
make this addition of the time required that these different affec- 
tions may be established, and then it will be seen how high is the 
number to which it is possible to arrive. 

True, this is the chronic progress, unmodified by treatment, a 
circumstance not likely to occur. The patient is nearly always 
subjected to treatment, and receives from some practitioner a mer- 
curial preparation. Now, it is admitted that these preparations 
have almost always the effect of retarding or of preventing and 
even of suppressing the development of the secondary accidents. 
The length of time that a more or less imperfect treatment may 
abridge the duration of the venereal disease, should therefore be 
represented when we speak of the full period of the disease. This 
is not all : in the column of the time required for the establishment 
of completely-confirmed syphilis, should figure the number which 
represents the time required for the removal of this diathesis, and 
the time required for its cure. ISTow, multiply by 2 the time re- 
quired for the establishment of the disease, and we shall scarcely 
obtain that needed for its cure. 

Add the whole together, and the sum will represent a period of 
such length as to render it impossible for the subject to gain a new 
chancre. It is known, besides, that some very distinguished prac- 
titioners maintain that confirmed syphilis is incurable. An indi- 
vidual affected with tertiary symptoms will always remain in that 
condition. If, therefore, my calculation be correct, and this 
opinion just, when we assert that an individual cannot have but 
once a disease which lasts for life, we proclaim a truth which is 
only but too true, an unfortunate circumstance for the unicists, 
especially since they have already stated that we can have the 
hydrophobia but once ! I shall still be met with the objections 
that observation proves that certain subjects have been able to ob- 
serve the origin, development, and disappearance of their diathesis 
in so short a space of time, as still to retain the power of enjoying 
pleasures, which expose them to syphilitic inoculation. This is 
true, and these are the cases precisely which furnish examples of 
the double infection. They may, indeed, contract a new chancre, 
a fact doubted by no one ; they may afterwards have consecutive 
accidents, symptoms of syphilis, which every one admits, but 
with a different explanation. Thus the unicists do not attribute 
the last accidents to the last chancre, but to the first, that is to 
say, to the chancre most remote ; and these accidents instead of 
indicating a new infection, according to their ideas, are but a re- 
lapse of the old disease. The first virus has remained dormant 
during a certain period of life, and on being roused new accidents 
appear. This is all hypothesis, coming to the support of other 
hypotheses, for the second consecutive accidents may be less pro- 



292 VIDAL ON VENEREAL DISEASES. 

found than the last which closed the era of the first contami- 
nation. 

Thus, statistics are wanting in favor of the unicity of syphilis, 
and opposed to it are clinical facts, which, in unison with experi- 
ment, do not permit the least doubt as to the possibility of one 
person having several attacks of the disease. I have already re- 
ferred to the inoculation performed by M. Bouley, physician of the 
Lourcine, who succeeded in producing a second syphilitic infection 
in a woman laboring under genuine tertiary symptoms. When 
treating of the mucous tubercles I analyzed the remarkable case 
reported by the interne of M. Bouley, which report forms part of 
an extensive article published in the Annates des maladies de ta peau 
et de la syphilis, (Nov. 1851.) I believe that when this experiment 
of M. Bouley shall become well known, we shall no longer place 
any value on syphilitic vaccination ; in other words, that the pox 
will not be given to patients to prevent the pox. 

Moreover, the effects of the diathesis vary in number, intensity, 
and gravity, and all cases of syphilis are not alike. There are 
different degrees ; some are more grave, more complete than others ; 
from the simple roseola and the most transient and benign 
manifestations of the diathesis, to necrosis, caries, and the visceral 
affections, showing a profound cachexy, there are several degrees. 
As it has been proved that the virus may be limited in its action 
to the production of a chancre, and after its reparation, may leave 
the constitution perfectly sound, it is also established that this same 
agent may produce only a syphilitic eruption, the cure of which 
depends upon that of the infection. But as chancre may be repro- 
duced by a new inoculation, by another infection, syphilis may 
also occur the second time. I have already stated, that such in- 
stances are regarded as relapses, and I have proved that such an 
opinion is a mere hypothesis. Those observers who have care- 
fully watched many cases of syphilis have observed relapses, espe- 
cially after an attack of blennorrhagia, which are passed in silence 
by the unicists, probably because blennorrhagia is not regarded as 
syphilitic. Thus, an individual may have repeated attacks of 
syphilis, especially of the milder forms. This may be explained 
by the fact of an incomplete saturation of the system ; it is said, 
that the first infection, being of short duration, still left the system 
time to become susceptible to the diathesis ; the second infection 
is explained by the greater power of the new virus which has been 
inoculated, and by the larger quantity taken into the system. It 
matters not, the fact remains, and the syphilitic unicity, which is 
but an hypothesis, vanishes. Neither the treatment nor the pro- 
phylaxis based upon it ; can have any foundation, any future. 



SECTION YH. 

THERAPEUTICS. 

The treatment of syphilis may be prophylactic or curative. I 
shall consider the latter only, the former having formed the subject 



THERAPEUTICS. 293 

of a separate chapter. On the appearance of what has been called 
the epidemic of the fifteenth century, practitioners viewing it as a 
new disease, with zeal and anxiety endeavored to find a means of 
combatting and arresting the scourge. They resorted to all the 
powerful therapeutic agents then in use. Analogy soon led to the 
employment of mercury, as for a long time this metal had triumphed 
ovex certain very obstinate cutaneous diseases; now, as syphilis 
often appeared as a disease of the skin, they were naturally led to 
try mercury ; the results were so satisfactory, and so well sustained, 
that this metal obtained, and still retains, a sway that cannot be 
seriously contested. I shall therefore enter upon the therapeutics 
' of this disease, by first considering this powerful agent. 

I.— MERCURY. 

Mercury was first administered externally, and afterwards in- 
ternally. 

EXTERNAL EMPLOYMENT. 

This metal has been combined with resins and with fatty sub- 
stances ; it also enters into the composition of ointments and pom- 
mades. In this latter form, and by frictions, mercury is most 
frequently employed externally^ and next to these in the form of 
vapor. 

Mercurial Frictions. — 1. Ordinary Method. — These are made with 
the double mercurial ointment, called the napolitain, which, how- 
ever, is not an ointment but a mixture of equal parts of lard and 
mercury. 

"When frictions were first used, their employment was always 
preceded by a cathartic and blood-letting. The latter may evi- 
dently be of service when the patient is young and of good con- 
stitution ; but it might be injurious in cases where the patient has 
already become enfeebled, or where he is naturally feeble. As to 
the cathartic, its use may be generalized with less inconvenience. 

To derive success from frictions the skin should be previously 
prepared. There must be either a degree of permeability, or rather 
of sensibility favorable to the absorption of mercury. For this 
purpose hot baths and diluent drinks are useful, and their employ- 
ment is also indicated during the whole course of the treatment. 
Five or six baths ordinarily suffice for the preparation, and even 
if it be difficult to procure them, we may, in simple cases, defer 
their use to the moment when we commence the administration of 
mercury. The bath should generally last for an hour, and should 
be of a temperature nearly equal to that of the body. In indi- 
viduals whose skin is naturally too dry we promote the good 
effects of the bath by rubbing, immediately afterwards, the whole 
surface of the body with the naked hands or a piece of flannel 
immersed in the oil of almonds, or other analogous oils. 

Feeble subjects, already exhausted by syphilis or some other 
protracted malady, should not bathe so frequently asrobust sub- 
jects. With such persons we may even abstain entirely during 



294 TIDAL OX VENEREAL DISEASES. 

the preparatory treatment ; and after the first frictions have been 
applied, the practitioner can judge according to the strength of 
the patient, whether one or two baths may not prove advanta- 
geous. 

Cold baths have also been prescribed during the preparatory 
treatment. They are adapted only to individuals not very ro- 
bust, the state of whose strength seems to require it, and they 
should be used only during the hot season. Then they produce a 
tonic effect, whilst at any other period of the year they would only 
add to the debility of these same patients. If, during the treat- 
ment by frictions, the bath cannot be employed, we should sub- 
stitute for them frequent lotions of soap and water. According to 
M. Lagneau, during these preparatory measures we must prescribe, 
as it is called, a soothing and humid regimen ; the patient should take 
only of such aliments as are of easy digestion, such as white meats, 
aqueous vegetables, and stewed fruits ; wine, the company of fe- 
males, and violent exercises, should be avoided. I approve of the 
latter measures, but I am not of the opinion that it is necessary in 
all cases to follow the regimen prescribed by M. Lagneau. Certain 
patients, on the contrary, require the use of tonics, for mercury 
produces great debility. 

Mercury, in every form, should be proscribed, when the vene- 
real accidents are complicated with acute inflammation, and par- 
ticularly when this condition which is observed almost exclusively 
in cases of recent infection depends upon the age and vigor of the 
subject. Before we resort to the use of frictions, the pain and ir- 
ritation should be subdued by means of diet, repose, baths, and 
antiphlogistics, both local and general. 

When the patient is once prepared, we should commence with 
the frictions. The first day, which at the latest should be the 
second after the administration of the purgative, we prescribe a 
bath in the morning, and in the evening we should employ fric- 
tion on one of the legs, from the internal malleolus and sole of the 
foot to the knee. A drachm of mercurial ointment should be 
used, and the friction should be continued from twenty minutes 
to half an hour. On the third day, another bath of longer or 
shorter duration, or lotions according to the strength of the pa- 
tient. The friction should now be made on the corresponding 
thigh, from the knee to near the scrotum ; on the sixth day, it 
should be made on the fore-arm ; on the eighth, on the arm ; and 
on the following days the frictions are repeated on the opposite 
extremity, commencing in the same manner, and following the 
same course, but constantly on one of the two days, and on the 
internal face of the thighs, where absorbent vessels exist in great 
numbers. The patients should cover these parts, after the frictions 
have been made, with thread stockings, linen drawers and waist- 
coat, which should be worn day and night, so as not to lose a part 
of the ointment on the clothes, which besides become so soiled 
that it is difficult to remove the stains. 

During the winter, in cold and humid countries, the parts on 
which the ointment has been rubbed should be covered with flan- 



THERAPEUTICS. 295 

nels, especially if the patients are compelled to be much exposed 
whilst engaged in their avocations. 

As to the baths, during the course of the treatment, they should 
be repeated more particularly when the patient is of a dry and 
bilious temperament, or very irritable, or when the nature of the 
symptoms require it, on the same days that we employ the fric- 
tions. Towards the end of the treatment, they should be used 
only once in three or four days. For the sake of cleanliness, the 
parts on which the ointment has dried, should be washed with 
soap and water. Patients who by debility or other causes are 
prevented from using the bath, should also wash their skin each 
time, with the soap and water. The treatment may, perhaps, be 
compromised by causing the frictions to be too rudely made, and 
thus at once inflame the parts subjected to the operation, irritate 
the skin, and retard the complete introduction of the mercury into 
the system. Frictions should therefore be used with gentleness 
and care. At the fifth or sixth application, the quantity of oint- 
ment employed should be doubled, being therefore two drachms ; 
we have, at this time, but little reason to apprehend a salivation, 
which does not occur until after the eighth or twelfth day. During 
the days that the friction is applied, the baths and lotions should 
be continued, and at other times the patient should be permitted 
to rest. In the meantime, a diluent or sudorific tisane may be 
given, according as we have to treat a primitive or consecutive 
affection, and the external symptoms should be treated as the case 
requires. 

The success of the antisyphilitic treatment does not absolutely 
depend upon the application of the frictions in the order which I 
have indicated. The result will be the same if, to please the pa- 
tient, the mercury be applied to the inferior extremities, and even 
to the legs exclusively, being careful, however, not to apply it 
twice to the same part, in order not to irritate the skin. W hen 
the strength permits, it is better that the patient himself make the 
application. Should he be too feeble for this purpose, it may be 
made by an assistant whose hand should be covered with a thin 
glove or a bladder, that it may not absorb a portion of the medi- 
cine. In cases of excessive corpulence, an assistant will also be re- 
quired. Patients may continue their occupations, and take their 
walks during the treatment ; for moderate exercise, by promoting 
perspiration, prevents the mercury from acting too much upon the 
mouth. But changes of temperature, cold, and especially cold 
combined with dampness, should be avoided. Thus, patients 
should exercise in the open air when the sun shines brightest, and 
not during the close of day or during the coldness of night. 

Those who strictly follow the rules prescribed, may expect a 
speedy cure. It must not, however, be supposed that a radical 
cure has been effected from the fact that the external symptoms 
have been removed. Daily experience teaches us that notwith- 
standing the occasional very prompt disappearance of these traces 
of infection, to destroy completely the syphilitic diathesis, the mer- 
curial frictions must be continued for about twenty or thirty days 



296 VIDAL ON VENEREAL DISEASES. 

in cases of recent infection, and for a much longer period when 
thej are of long standing. This is the opinion of onr predeces- 
sors, as expressed by M. Lagneau. According to this practitioner, 
the ordinary quantity of mercnrial ointment required to cure a 
recent case of syphilis, is not far from four to five ounces. To 
overcome obstinate and troublesome symptoms, this quantity may 
be raised to from six to eight ounces. Instances have occurred in 
which even two pounds have been used in a single case. 

2d. Method of Pihorel. — After the usual preliminary treatment, 
Pihorel applies frictions to the soles of the feet, the palms of the 
hands, the internal surface of the thighs, or the arms and wrists, 
with the following ointment : 

I£ . Ungt. Napolitain, § iii. 
Sulph. Calc. Ammon. § i. 

Mix thoroughly. Use at first half a drachm, morning and evening ; 
the dose should be increased to two ounces for each application. The parts 
are to be previously ivashed ; cover them, after the ointment lias been ap- 
plied, with mittens, stockings, or gloves, which should be ivorn for two or 
three hours. 

Besides the other advantages of this method, it is claimed that 
it does not soil the patient's linen, because the sulph. calc. ammon. 
causes the ointment of Pihorel to unite readily with the soap and 
water. 

The inconveniences attending the method of treatment by fric- 
tions, its want of cleanliness, and the difficulty of appreciating the 
quantity of the metal absorbed, have led to the adoption of other 
means, of which I proceed to give a detailed account. 
. 3d. Method of Peyrile. — The accessory measures are here omitted. 
The frictions are confined to the mucous lining of the glans and 
the prepuce. The penis is bathed before the ointment is applied. 
Frictions are made with two ringers, and continued for fifteen 
minutes, twice a day ; a drachm of ointment is used. After three 
or four days, symptoms of salivation appear. The frictions are 
then to be omitted, and not to be resumed until after the expira- 
tion of forty-eight hours. The quantity of ointment is increased 
till a drachm is employed in the morning, and the same quantity 
in the evening, that is, double that used at first. According to 
Peyrile, twelve days suffice for recent affections, and twenty-five 
for those of long standing, the cure being thus made certain ! It 
occasionally happens that these frictions irritate the glans, and 
cause it to become tumefied, thus causing the patient considerable 
anxiety. He should be informed of the probability of such an 
occurrence. Warm local baths, and the discontinuance of the 
mercury for twenty -four hours, are sufficient to restore the parts 
to their normal state. 

4th. Method of Scatigna. — This is called the mercurial treatment 
by application. From fifteen grains to one drachm of ointment is 
applied to each axilla, and the naked arms are brought against the 
trunk. This is repeated every second day; in the evening the 



THERAPEUTICS. 297 

patient lies down well covered, and thus remains until the follow- 
ing morning. So active is the absorption, that nothing remains 
in the axilla. 

This application is less filthy than that by the ordinary mode 
of friction. The exact quantity of mercury absorbed may be 
known ; but in certain subjects it irritates the axilla, the internal 
surface of the arms, the side of the chest, producing a papular 
erysipelatous eruption. 

5th. Method of Cirillo. — He employs frictions with an ointment 
of bi-chloride of mercury mixed with lard, according to the fol- 
lowing formula: 

$ , Hydrarg. Bi-chlor, 3 i. 
AxuDg. | i. 

Triturate in a glass mortar for tivelve hours, and add : 
Hydro-chlor Amnion. ^ i. 

The preliminary measures are baths, lavements, decoctions of 
dog's-grass, and sarsaparilla. 

A drachm of the above ointment is rubbed on the soles of the 
feet, the application to be made in the evening only. This part is 
selected because other portions of the skin might become irritated, 
and even excoriated by the medicine. These frictions are repeated 
every second day. On the fourth day, a bath is administered, 
and on the following day one and a half drachms are to be used. 
This course is to be pursued until the cure is completed, with 
diluent drinks and a bath every third or fourth day. The quan- 
tity of ointment employed should never exceed two drachms at 
once. 

6th. Method of Glare. — It is proposed by the English surgeon to 
produce absorption of the calomel by the mucous membrane of the 
mouth. Half a grain or a grain of calomel is rubbed on the in- 
ternal surface of the mouth, in the vicinity of Steno's duct, two or 
three times in a day. But, as the calomel may thus be swallowed, 
Clare rubs it on the gums and internal surface of the lips, direct- 
ing the patient not to spit or to swallow the saliva until the powder 
has been completely absorbed. The patient must also be careful 
to take no drink for half an hour. In serious cases, Clare employs 
as a supplementary application, an equal number of frictions on 
the tongue, calomel in all cases being used, even in the dressing 
of the ulcers in the mouth and on the genital organs. Clare aims 
at a salivation, and as, by his method, this is speedily produced, 
and sometimes with beneficial effects on the external symptoms, 
he imagines that he has thus effected numerous and speedy cures, 
which, in the majority of cases, could have been but temporary. 
That Clare himself has observed relapses, is proved by the fact 
that in cases especially of confirmed syphilis, we find that he gen- 
erally uses the corrosive sublimate. 

This method was not well received in France, and is not here 
much employed, for whatever may be the precautions taken, a 
part of the powder is either swallowed or rejected with the saliva. 



298 VIDAL Otf VENEREAL DISEASES. 

The quantity absorbed, therefore, cannot be correctly estimated, 
as salivation occurs most frequently and quickly, and especially 
as the results obtained by those who have imitated Clare, are far 
from corresponding with those proclaimed by the inventor him- 
self. M. Brachet has vainly attempted to revive in France the 
method of Clare, by employing a modification of it, which consists 
in placing the calomel or the mercurial salt on the end of the 
tongue, and with the latter organ frictions are made against the 
palatine arch. 

Lotions and Mercurial Baths. — The use of corrosive sublimate 
lotions is a very old practice ; they were employed as dressings to 
certain primary ulcerations. Mathiole afterwards, with a view of 
acting not only locally, but upon the whole system, bathed the 
surface of the whole body with a lotion composed of two ounces 
of corrosive sublimate to six pounds of water, distilled with plan- 
tain, roses, and solanum. This treatment was proposed both for 
the primitive and the consecutive accidents. But as cutaneous 
absorption varies greatly in different subjects, and even in the 
same individual, under different circumstances ; as the integuments 
sometimes inflame, and thus become painful (for the proportion 
of the sublimate is large), these lotions have been renounced. 

M. Meyrieu would substitute for these lotions frictions, with two 
and a half drachms of a solution, composed of half a drachm of 
corrosive sublimate, two ounces of water, and half a drachm of 
alcohol. These frictions are made in succession to the soles of the 
feet, the legs and the thighs. 

The sublimate solution is now used externally only under the 
forms of -baths. 

BI-CHLORIDE BATH. 
^. Hydrarg. Bi-chlor. § ii. 
Dissolve in a small quantity of distilled water mixed with alcohol, and 
pour into a sufficient quantity of common water for a general hath. Wlien 
intended for a child t/ie quantity of sublimate should not exceed one 
drachm, and in the adult not more than two ounces. 

Fumigations. — This is certainly one of the most ancient methods 
of administering mercury : for certain cutaneous affections were 
thus treated long before the so-called epidemic of the fifteenth cen- 

tur y- 

Mercurial fumigations have at times been highly extolled, then 

neglected, but never completely abandoned, since, even at the 

present day, they are still used in certain obstinate affections of the 

throat, nasal fossae, and syphilitic accidents which have resisted 

every other method of treatment. 

The red sulphuret of mercury (cinnabar) was at first, and is still 

for this purpose employed. Calomel, mixed with the protoxide 

of mercury, has been occasionally -substituted for it. Calomel 

with albumen, the metallic mercury united with the chloride of 

iron, and, finally, mercury alone and its red oxide mixed with 

inert substances, have all been tried. 



THERAPEUTICS. 299 

As the fumigations are generally employed in cases of long 
standing, it is well to unite with them sudorifics. From the time 
of Glauber and Lalouette, a large box has been used in which the 
patient may receive the mercurial vapor, without being forced to 
respire it, as was the ancient custom. This box is the same as that 
perfected and rendered useful by MM. Gales and d'Arcet, for the 
treatment of the itch and other cutaneous affections. 
" There are no fixed and positive rules for the administration of 
mercurial fumigations, for the nature, the severity of the case, and 
the temperament of the patient, may compel the practitioner to 
vary daily the application of this method. However, it is very 
common to employ the fumigation every other day. Sometimes 
they are used two days in succession, and the patient is allowed to 
rest on the third. Occasionally he is suffered to rest for forty- 
eight hours. 

Two drachms of one of the powders which I shall soon men- 
tion, are generally employed. In moderately-severe cases, from 
twenty to twenty -five fumigations are used, but in severe cases, 
the number reaches as high as thirty, forty, and even higher. 

I have already stated how fumigations are generally adminis- 
tered ; the patient being placed in a large box. When we wish 
to act locally, we make use of a funnel to direct the vapor, or the 
shower-bathing apparatus to be found in a multitude of establish- 
ments in Paris. The extremity of the tube conducting the vapor 
is directed on an exostosis, on the genital organs, to the throat and 
nasal fossa, in the case of obstinate ulcerations. Of course, in 
order to reach cavities, the calibre of the tube must be diminished, 
and we must proceed gently, with small quantities of the mercurial 
preparation. As the saline powders possess a great degree of 
activity, the gray oxide of mercury should be preferred. 

[Mr. Langston Parker is doubtless the warmest partisan of this 
mode of treatment, and, so extensive has been his experience, that 
his remarks are entitled to the greatest consideration. Its advan- 
tages, he states, are, that in ordinary cases, it requires no confine- 
ment ; never impairs the appetite ; does not produce salivation, 
or ulceration of the mouth, mercurial erythismus or blotches on 
the skin ; and, if associated with internal treatment by mercury, 
reduces what is required to an exceedingly minute quantity. "la 
addition to this, treatments according to my plan are safer, quicker, 
more certain, less frequently followed by relapses, indeed very 
rarely so, and again are capable of working cures in obstinate cases 
which have resisted all other modes of treatment." He applies 
the vapor of the bi-sulphuret, gray oxide, bin-oxide, or iodide of 
mercury in a moist state, to the whole surface of the body, by 
which, after the continuance of the process for twenty or thirty 
minutes, profuse perspiration is induced. This process is repeated 
as frequently as the nature of the case may require till a cure is 
effected, and is or is not associated with internal medicines. The 
patient is placed on a chair, and covered with an oil-cloth, lined 
with flannel, which is supported by a proper framework. Under 
the chair are placed a copper-bath containing water, and a metal 



300 VIDAL ON VENEREAL DISEASES. 

plate, on which is put from one to three drachms of the bi-sul- 
phuret of mercury, or the same quantity of the gray oxide, or the 
bin-oxide. Under each of these is a spirit lamp. Heated air, com- 
mon steam, and the vapor of mercury, are thus applied to the 
whole surface of the body in a moist state. At the end of twenty 
or thirty minutes, the lamps are removed, and the temperature 
gradually allowed to sink ; when the patient has become moder- 
ately cool, the coverings are removed, and the body rubbed dry. 
A cup of warm decoction of guaicum, sweetened with syrup of 
sarsaparilla, is then administered. The apparatus can be modified 
to suit particular cases. Mr. P. considers this method vastly 
superior to that by the dry fumigation. His little volume, " On 
the Treatment of Secondary, Constitutional, and Confirmed Syphilis, by 
a Safe and Successful Method" we most cordially commend to the 
attention of those who desire to become acquainted with the true 
value of mercurial fumigations in the treatment of syphilis. In a 
recent interview with Mr. P., he informed us that every day's ex- 
perience strengthened his faith in the efficacy of this plan. Dr. 
Gibson also speaks highly in praise of this method, and recom- 
mends its administration in a manner similar to the above. — 
G. C. B.] 

INTERNAL USE OP MERCURY. 

Metallic Mercury — la this state, it has been employed from the 
earliest period of the mercurial treatment. To divide it, and thus 
facilitate its administration, the mercury has been united with 
other substances. A considerable number of formulas have at 
times been praised, and in turn abandoned. Two remain, and will 
probably remain in practice : they are those of Belloste and Se- 
dillot. 

pills OF belloste {Modification of Baumes). 

Tfc . Quicksilver, J i. 

Potass. Bi-Tart. 3 i. 

Diagrydium, § i. 

Jalap, § i. 

Made into pills of three grains each. From two to six to be taken daily. 

These pills resemble those of the famous Cheradin-Buberousse, 
which had so great a reputation ; but they are now rarely em- 
ployed in the anti-syphilitic treatment. They are intended to 
act chiefly as a purgative. For that purpose from twelve to 
twenty may be given in the day. I have observed the good 
effects of these pills in cases of very obstinate mesenteric engorge- 
ments. 

When we wish to act at once on the syphilitic virus, the follow- 
ing pills are to be preferred : 



THERAPEUTICS. 301 

PILLS OF SEDILLOT. 

]£ . Ungt. Hydrarg. § iii. 
Sapon. Offic. |ii. 
Pul. Glycyrrh. § i. 

Make into pills of from three to five grains, each, of which contains about 
one grain of tJie metal. From tivo to ten are to be taken in the twenty four 
hours. 

H. Bayer, who highly praises Sedillot's pills, makes them accord- 
ing to the following formula : 

I£. Ungt. Hydrarg. duplex, gr. xlv. 
Sapon. Offic. gr. xxx. 

Pulv. Glycyrrh. gr. xv. 

Make into pills of three grains. Dose, tivo for a female, three for a 
male, during the day. 

Instead of taking the ordinary mercurial ointment, the metal is 
mixed with the butter of cocoa, and the pills thus made are very 
much employed : 

3 • Ungt. Hydrarg. with butter of cocoa recently prepared, § ii. 
Sacch. Pulv. 3 ii. 

Muc. Gum Arab. q. s. ft. 

Forty-four pills, of which from three to twelve may be taken in the 
twenty-four hours. 



MERCURIAL COMPOUNDS. 

Metallic mercury, as we have seen, must be administered in very 
large doses to produce the desired effects, and this is an incon- 
venience ; it has therefore been combined with other substances, 
and thus been rendered much more active, whilst it may be ad- 
ministered in much smaller quantities. 

The Chlorides of Mercury. — These are among the combinations 
most employed, especially the bi-chloride. 

1st. Proto-chloride. — The proto-chloride, or calomel, which was 
formerly so much employed, and is now but seldom used in the 
treatment of affections really syphilitic. Being insoluble, to pro- 
duce curative effects, it must be administered in very large doses, 
and then it too frequently and too speedily produces salivation, 
and acts too powerfully on the intestinal canal ; it is used as a 
purgative much more frequently than an anti-syphilitic. The fol- 
lowing formula is still retained in the anti-syphilitic therapeutics, 
because it is less apt to excite ptyalism than the others : 

]J. Hydrarg. Proto-chlor. gr. iv. 
Opii. gr.^ ii. 

Extr. Glychirr. moll. 3 i. 



302 VIDAL ON VENEEEAL DISEASES. 

2d. Bi-chloride of Mercury, or Corrosive Sublimate. — This prepara* 
tion was long since known, when Bich, Wiseman, Hoffman, and 
Boerhaave recommended it as an anti-syphilitic. Its use was much 
more efficacious and more extensive when Yan Swieten regulated 
its mode of administration after the practice of Boerhaave. The 
following is the formula for the famous liquor which still bears the 
name of Yan Swieten. I copy it from the last Codex : 

VAN SWIETEN'S LIQUOE. 

^. Bi-chlorid. Hydrarg. 1 pt. 
Aq. pur. 900 pts. 

Alcohol rect. 100 pts. 

This compound contains the one-thousandth part of corrosive 
sublimate. It is administered at first in the dose of a tablespoonful 
in a glass of sugared water, milk, or gruel, which destroys the 
metallic taste of the liquor, which is more or less decomposed, 

M. Puche prefers the following solution : 

CHLOEO-MEECUEIAL SOLUTION". 

^ . Bi-chlor. Hydrarg. gr. xv. 
Sal. Marin. 3 i. 

Aq. dist. | xvi. 

To be used in all cases of constitutional syphilis, in doses of from one to 
one and a half ounces in tlie day ; let the patient drink half a pound of 
some sudorific tisane, at four different doses, after regular intervals. 

To obviate the disagreeable taste of the solutions of the bi-chlo- 
ride, and to disguise the medicine, it is now made into pills. 
Yarious formulas are used. The following is the one which was 
preferred by Cullerier and Dupuytren : 

culleeiee's meecueial pill. 

I£. Bi-chlor. Hydrarg. gr. xv. 

Farm. Trit. Hyb. § ss. 

Grum pulv. 3 ss. 
Aq. dist. q. s. ft. 

Pills of two and a half grains each. Dose, two morning and evening. 

In describing the treatment of chancre I have already mentioned 
the formula which I prefer ; it nearly resembles that of Dupuytren. 
My formula contains the fifth part of a grain of the sublimate. 
That of the illustrious surgeon just named was as follows : 



^ . Bi-chlor. Hydrarg. T \ to £ grain. 
Ext. Opi. Gum, i or | grain. 
Ext. G-uaic. grs. 4. 

Make one pill. Dose, two in the day. 






THERAPEUTICS. 303 

I have already stated that I employ the bi-chloride in cases of 
primary affections only. In confirmed cases of syphilis I adopt 
the following means : 

Combinations of Iodine and Mercury. — These were introduced by 
Biett. They are therefore new agents, and yet they have already 
attained a reputation surpassing that of the bi-chloride of mercury. 
There can be no doubt, as has been proved, especially by^ M. 
Cazenave, that the syphilitic eruptions are beneficially modified 
by the compounds of iodine and mercury, and this, too, after the 
bi-chloride has failed. 

Biett tried at first the bin-iodide ; he united it with the expressed 
juice of the lactuca sativa (thridace). But its great activity and 
ohfficulty of management caused the proto-iodide to be preferred by 
Biett and his pupils. 

M. Puche has returned to the bin-iodide ; he combines it with 
iodide of potassium, as follows : 

m. puche's solution of iodine and mercury. 

3 . Bichlor. Hydrarg. gr. viii. 

Iodid, Potass. gr. viii. 

Tine. Saffron, f i. 

Aq. pur, | xvi. 

From one to four ounces a day in a sudorific tisane. 

M. Puche employs this solution in cases of indurated chancres 
to prevent constitutional infection ; and especially in the treatment 
of the tardy secondary accidents. 

The following pills may be substituted for the solution : 



m. puche's pills of iodine and mercury. 

^. Bichlor. Hydrarg. grs. viii. 

Iodid, Potass. grs. viii. 

Amyl. 3 iss. 

Gum Arab. 3 ss. 
Aq. q. s. ft. 



Pills fifty. They should be covered with gelatine to protect the fauces 
from their irritating effects. Dose, from two to ten in the day. 

The above formulas are copied from the notes of M. Puche 
himself. The proto-iodide, however, is the preparation preferred 
by the great majority of practitioners. M. Cazenave, for example, 
gives it in doses of from one to three grains in the day. In the 
milder forms of the syphilida, and in subjects somewhat irritable, 
he uses the following : 

^ . Prot. Iod. Hydrarg. grs. viii. 
Thridace 5 v. 

Make twenty pills. One to be given at first, then from two to four in 
twenty four hours. 



304: VIDAL ON VENEREAL DISEASES. 

In the severer forms, as for example the tubercular, this is the 
formula adopted by M. Cazenave : 

]J. Proto-iod. Hydrarg. 3 ss. 
Thridace, 3 i. 

Make forty pills. Dose, one at first, then from two to four in the 
twenty four hours. 

This is the quantity most generally administered by M. Ricord 
in all cases of secondary affections. He makes fifty pills with 
forty-five grains of the proto-iodide, and the same quantity of 
the thridaces, and a certain quantity of opium and conserve of 
roses. 

As I am satisfied that the interruptions of the mercurial treat- 
ment are injurious, and as large doses of the proto-iodide act 
promptly on the mouth, and the intestinal canal, I gradually ac- 
custom the system to the influence of this medicine. I adopt 
the following formula : 



]£. Proto-iod. Hydrarg. gr. xv. 
Thridace, gr. xv. 

Conserv. Ros. q. s. ft. pill 30. 

One to be taken morning and evening. Occasionally I have given but 
one in the day. Gradually the dose is increased, so that instead of 
thirty Intake but tiventyfive pills ; tlien twenty containing fifteen grains 
of the proto-iodide. hi subjects with a very irritable intestinal canal, es- 
pecially females, for the thridace I substitute four grains of the gummy 
extract of opium. 

Cyanuret of Mercury. — Biett and Parent-Duchatelet have praised 
this salt. The latter has even made experiments for the purpose 
of determining the practical value of the new anti-syphilitic agent. 
He commences by giving T \ of a grain, at the onset of the attack ; 
then it is increased to T V | of a grain, and even to I a grain. 
Parent makes tinctures of the cyanuret, also pills, solutions, gar- 
gles, and pommades. According to Parent and others who pro- 
claim the praises of the cyanuret of mercury, this compound has 
the following advantages : 1st, it does not produce the pains in 
the epigastric region, which is partly attributed to the salts of 
mercury; 2d, it is less easily decomposed than the bi-chloride; 
3d, being more soluble than the latter salt, its action should be 
more prompt, and hence its more rapid cures. It would seem that 
these and other advantages have not given to the cyanurets of 
mercury a precedence over the bin-iodide and the proto-iodide, 
which are still most frequently employed. True, as I have already 
stated, the cyanuret was introduced at a later period, and experi- 
ence has not yet fully decided on its virtues. The following are 
Parent-Duchatelet's pills : 



THERAPEUTICS. 305 

PILLS OF CYANURET OF MERCURY. 

]J. Bycyanid. Hydrarg. gr. v. 

Opi. crud. gr. xii. 

Mic. pan. 3 i. 
Mel. q. s. ft. pil. 96. 

Each pill contains T V grain of the cyanuret, and \ grain of opium' 
I have already mentioned the dose of the cyanuret administered by 
Parent. 

IL—OTHER MERCURIAL PREPARATIONS. 

The acetate of the deutoxide of mercury, which forms the base of 
Heyser's pills, has also been employed. The prolo-tartrate of mer- 
cury has been highly recommended by Pressarin, a surgeon of 
Lyons ; it forms a liquid called the vegeto-mercurial water. It is 
known that the proto-nitrate and the acetate of mercury consti- 
tute the active part of the syrup of Bellet, so highly praised by 
Bouvart, and which exists only in name on some labels. Finally, 
we have also the deuto-nitrate, and then the protophosphate of mer- 
cury. All of these compounds, the offspring of industrious minds, 
or the desire of doing something when nothing better could be 
done, have now fallen into that oblivion which they merited. 

III.— ACCIDENTS PRODUCED BY MERCURY. 

The introduction of a certain quantity of mercury into the sys- 
tem occasionally produces accidents which it is important to un- 
derstand, that they may be avoided and combatted ; at the head 
of these must be placed salivation or stomatitis, after which may 
be placed mercurial tremors. 

SALIVATION AND STOMATITIS. 

This accident has been observed from the most remote periods, 
when mercury was employed in the treatment of certain cutaneous 
affections. Thus, Avicenna prescribed the gargles which should 
be employed. The attention of our predecessors was more par- 
ticularly arrested by the more or less considerable flow of saliva, 
and this phenomenon was attributed to the action of the mercury 
on the salivary glands, or other secretory organs. At the present 
day, it is supposed to be the result of an inflammation of the 
gums and living membrane of the mouth ; the action on the sali- 
vary glands is completely denied, though without cause. 

Salivation is much less common now than in former times, as 
we endeavor to avoid it, regarding it as an accident, whilst our 
predecessors provoked it with large doses of mercury, or by the 
method of its administration, believing it to be a favorable crisis in 
the treatment of venereaL diseases. However this may be, it is 
important to be acquainted with this accident, both on account of 
its prophylaxis, and its therapeutics properly so called. 

Causes. — Children under seven years of age are very seldom 

20 



306 VIDAL ON YEXEREAL DISEASES. 

salivated. During the period of the first dentition, indeed, mercury 
acts rather on the digestive organs than on the mouth. Certain 
temperaments and morbid conditions predispose in an especial 
manner to ptyalism ; thus the lymphatic, the strumous, and scor- 
butic, or the latter alone. Certain states of the intestinal canal, of 
the mouth, predispose to ptyalism ; as for example, habitual con- 
stipation, and especially neglected carious teeth. Salivation is ob- 
served more frequently in females than in males. In females the 
mercury more frequently acts on the intestinal canal, which has 
led to the assertion that females do not well tolerate the use of 
the medicine. 

Certain modifications of the integument, especially sudden 
changes, may produce salivation. Thus the sudden exposure to 
the action of cold and moisture, by checking perspiration, promote 
the development of ptyalism, for this reason it occurs less fre- 
quently in summer than in winter. This should teach us to pro- 
tect the patient from the effects of cold during the administration 
of mercury. But it has also been observed, that a high tempera- 
ture may produce the same result. This is especially the case 
with artificial heat ; thus, when it was the custom to confine pa- 
tients after the use of frictions, in small and heated rooms, patients 
who passed their days over heated stoves were most generally 
salivated ; a fact explained by the determination to the head under 
such circumstances. Whatever opinions may be entertained with 
reference to the action of heat or cold, the practitioner should 
guard the patient from the excesses of either. 

Vain attempts have been made to combine mercury with the 
substances which should so modify its action as to prevent saliva- 
tion. For this purpose it has been united with sulphur, camphor, 
&c. ; but the mouth under certain circumstances and in certain 
doses, always becomes affected. This arises from the fact, that the 
special action on the mouth does not depend upon this or that 
mode of preparation, since whatever the latter may be, when once 
introduced into the system, its effect on the constitution and the 
mouth is the same ; for all mercurial 'compounds undergo a change 
which reduces them to a single form. Such at least was the 
opinion of Hunter, and M. Mialhe has lately proved that every 
mercurial compound, when introduced into the stomach, becomes 
changed into the bi-chloride of mercury. Thus the effect depends 
not upon the particular preparation, but on the quantity of mercury 
taken into the system. We can therefore understand how the 
preparations and applications which permit the speedy and abund- 
ant absorption of the metal, without immediate unpleasant conse- 
quences, will most frequently produce salivation ; the compounds 
on the contrary, whose local effect is powerful, will more rarely 
excite ptyalism, for the reason that the quantity used is necessarily 
moderate. From this it follows that mercurial frictions, the local 
action of which is unimportant, and which enables us to introduce 
a large quantity of mercury into the system in a short space of 
time, are speedily followed by salivation ; the same result attends 
the internal administration of the insoluble salts, as, for example, 



THERAPEUTICS. 307 

the proto-cliloride of mercury. The bi-chloride and the bycyanide 
of mercury very seldom produce ptyalism, because the corrosive 
action compels the practitioner to administer them in very small 
doses. Thus, salivation depends upon the quantity used within a 
given time, and not upon the form in which the metal is adminis- 
tered. Of course this quantity depends also upon the individual, 
for some are salivated after two applications of the frictions, whilst 
others are never so affected. I have already remarked that chil- 
dren under seven years of age do not become salivated. 

Symptoms and Progress. — From what I have stated, it is evident 
that the commencement of salivation varies according to the quan- 
tity of mercury at first administered. Thus, when the employ- 
ment of frictions was almost general, ptyalism was often observed 
on the fourth day. At the present time, with the proto-iodide for 
example, in doses of one and a half grains, and this quantity not 
exceeded, salivation generally occurs during the course of the 
first week. Each increase of the quantity increases the probability 
of ptyalism ; thus patients have been seen to tolerate well the or- 
dinary dose of the proto-iodide for eight or fifteen days, and yet 
whenever one grain was added to the the above quantity the 
mouth would become affected. But if we proceed more cautiously, 
if instead of increasing the dose one grain, we add fractions of 
a grain, the dose may be increased to three grains daily without 
causing the mouth to suffer 

I proceed to examine the symptoms beginning with the mildest, 
or those included in the first degree. At first there is redness and 
tumefaction of the gums ; they are very painful especially on pres- 
sure ; they are soft and have a fungous feel ; they bleed and sepa- 
rate from the necks of the teeth which are slightly loosened. The 
gums on the lower jaw are first affected, and generally the mu- 
cous membrane behind the wisdom teeth, especially when they are 
not fully through, or are in the process of cutting ; then follow the 
upper gums, and finally, the cheeks, the edges of the tongue, and 
the lips become affected. At the points subjected to pressure by 
the molar teeth, especially at the depressions corresponding to 
the bodies of the teeth, and on the ridges corresponding to the in- 
terspaces between them, the effects may also be discovered. Be- 
tween the inferior and superior depressions is a very prominent 
ridge, directed horizontally from before backwards ; it arises from 
the separation made by both jaws, a separation more prominent 
than natural, which is explained by the swelling of the mucous 
membrane of the adjacent parts, and the pain which prevents the 
teeth from coming in contact with each other. The arch and the 
velum of the palate, its pillars, the tonsils, the uvula, and occasion- 
ally the pharynx, become involved in these pathological changes. 
The glands of the mouth are often enlarged, the tongue is turgid, 
red and painful on motion, and its edges have the appearance of 
festoons which are the imprints of the teeth ; its papillae are so me- 
times more prominent than in the normal state. All the move- 
ments of the tongue and the buccal parietes are more or less im- 
peded or rendered impossible, by the swelling of these parts, and 



308 VIDAL ON VENEREAL DISEASES. 

those of the tongue in particular by the tumefaction and the pain. 
The mouth has a repulsive and peculiar fetor. The patient is an- 
noyed by a constant disagreeable metallic taste. The sub-maxil- 
lary glands, in which the lymphatic vessels of the mouth termi- 
nate, are engorged. Sometimes the upper part of the neck be- 
comes tumefied ; and the lips and cheeks puffed to a considerable 
extent. 

As I have stated, it was once supposed that the salivary glands 
were the parts primarily and principally affected. At the present 
day, some authors believe that they are never involved. This 
opinion is erroneous. Nevertheless, it is very certain that even 
in the case of inflammation of these glands, its severity does not 
always correspond with the quantity of fluid secreted. The 
lymphatic glands are at least as often affected as the salivary 
glands, which is very seldom, and perhaps never the case unless 
when the inflammation extends from the lining membrane of the 
mouth, as may occur in any inflammation of this membrane. These 
cases of adenitis seldom attain any considerable severity, and very 
rarely terminate in suppuration. Such a termination is still more 
rare with the salivary glands. 

The quantity of saliva which escapes is sometimes very trifling, 
particularly in the first degree of the affection ; but if the treat- 
ment be not gradually suspended in twenty -four hours, the pa- 
tient may lose much more than would be imagined. Cases have 
been cited in which as much as eight pounds have been lost in 
this space of time. The head is flexed, and supported by the 
hand, the lips swollen, the tongue tending to protrude from the 
mouth, and the latter is open to permit the saliva to escape. 

Fallopius asserted that the saliva thus discharged, contained 
mercury in solution. M. Colson has again advanced the opinion, 
that we may assure ourselves of the presence of the metal by 
plunging into the saliva a blade of gold or of copper. Chemists, 
such as Christison, Ehodes, Meisner, and Bostock, who have re- 
peated this experiment and employed proceedings the most deli- 
cate and varied, have constantly arrived at negative results. Ac- 
cording to Bostock, the most remarkable character of the saliva 
in syphilitic patients, that is, in those who have been subjected to 
mercurial treatment, consists in the very great diminution in the 
proportion of the mucus. The saliva is rather serous than mu- 
cous. Indeed, this fluid in ptyalism is secreted in too great an 
abundance to be completely elaborated ; the same condition ob- 
tains with all the secretions. 

I have thus described the symptoms in their highest intensity, 
of the first degree of stomatitis. In the second degree, these symp- 
toms in becoming developed, impress a new character on the dis- 
ease which now presents another aspect. Bright red patches ap- 
pear at every point of the buccal mucous membrane in contact 
with the teeth. But the peculiar characteristics are diphtheritic 
productions, a kind of plastering which is seen on the free border 
of the gums, and the upper surface of the tongue ; these pseudo- 
membranous formations are also to be seen on the internal surface 



THERAPEUTICS. 309 

of the lips, cheeks, on the sides of the tongue, precisely at the 
points which correspond to the dental arches. 

When the symptoms reach the third degree, the diphtheritic for- 
mations disappear, and in their place are found ulcerations and 
loss of substance of the mucous membrane. 

The fourth degree is characterized by a more considerable loosen- 
ing of the teeth, which sometimes drop out ; for the inflammation 
of the mucous membrane, which in the first degree was confined to 
the internal layer of the dental follicle which is in connection with, 
and adheres to the neck of the teeth, now involves the periosteal 
lining of the sockets of the teeth ; thence the separation of the 
surfaces which it covers, that is the teeth and alveoli ; and thence 
the loosening and loss of the former and the necrosis of the latter. 
The action of the mercury may be such upon the mouth, that the 
gums, the tongue, and the cheeks, sometimes mortify. These 
cases are excessively rare, for this blind and obstinate administra- 
tion of mercury, when the mouth is already affected, is not a char- 
acteristic of our day. 

The cases are exceptional in which we observe a fever some- 
what peculiar during the course of a salivation. In some cases, 
the pulse becomes a little frequent and the skin hot ; there are 
cephalalgia, sleeplessness, general prostration, and anorexia. Occa- 
sionally there is considerable discoloration of the tissues, the face, 
especially, being very pale ; the patients become emaciated, di- 
arrhoea and tremors supervene, with or without paralysis ; but 
these are complications which are very seldom observed at first, 
and only when we persist in administering mercury, notwithstand- 
ing the existence of the stomatitis. 

It is rare that stomatitis passes through the three degrees, which, 
for the purpose of facilitating their study, I have described. At 
the present day it is almost always partial, and confined to one 
point of the gums, or of the buccal mucous membrane, and it lasts 
for some days or weeks. 

Diagnosis. — The mercurial are liable to be confounded with the 
syphilitic ulcerations. I pointed out their differences when speak- 
ing of chancre. M. Grappin has established further distinctions in 
an excellent Thesis. He observes : 

" The diagnosis of mercurial stomatitis is never difficult ; it can- 
not be confounded with simple stomatitis, and that produced by 
certain agents, as emetics for example, for it is rare that we are 
not informed of its cause, and this knowledge suffices ; even in the 
absence of such information, the fetor of the breath, and the 
loosening of the teeth will soon remove all doubts. It is easy also 
to distinguish mercurial ulcerations from those produced b} r the 
syphilitic virus. Indeed, the first occupy the internal surface of 
the cheeks, lips, and sides of the tongue, and correspond to the 
projections of the teeth; the others most generally affect the inner 
surface or borders of the lips, the commissures, the upper surface 
of the tongue, as well as its sides, the velum palati, the tonsils, the 
superior and middle part of the pharynx. These syphilitic ulcers 
are deep, and circular, with elevated and perpendicular edges ; 



310 



VIDAL ON VENEREAL DISEASES. 



their base is of a grayish dirty color ; the mercurial are superficial, 
irregular, and covered with whitish membraniform concretions, 
and are few in number ; lastly, the ulceration is always preceded 
by redness and tumefaction of the mucous membrane, and ptyal- 
ism. Add to this the fact, that mercury always aggravates mercu- 
rial ulcerations, whilst the syphilitic are advantageously modified 
by it."* 

Prognosis. — This may be regarded in two points of view : 1st, 
with reference to the local disorders and the effects on the consti- 
tution, and independently of the consequences which salivation 
may produce in the treatment of syphilis ; 2d, with reference to 
this treatment. 

A. As to the general and local disorders resulting from the use 
of mercury, administered as at the present day, it may be said that 
it is rare, exceedingly rare. Thus it is necessary that we obsti- 
nately adhere to the doses and the mode of administration which 
affect the mouth ; and that the patient be placed under unfortun- 
ate hygienic conditions, and his constitution be profoundly debili- 
tated, in order that we may observe these mortifications of the 
cheeks, of the tongue and gums, which leave behind such losses 
of substance, and deformities, to interfere with the functions of the 
parts. The general effects are, nervous symptoms and exhaustion, 
results of a salivation not only abundant, but very prolonged. 
Now, I repeat, it is rare that practitioners do not prevent these 
accidents by the moderation of the doses, and the precautions 
which they take to suspend the administration of mercury when 
the mouth begins to be affected. 

B. As to the second point of view, that is, its bearings upon the 
treatment of syphilis, the opinion is no longer entertained as form- 
erly, that it is of advantage. It was supposed, indeed, that the 
virus might be drained away by means of the perspiration, an 
intestinal flux, and especially by a flow of saliva, and there was a 
method of treatment called that by salivation, which was for a long 
time followed, and is yet occasionally employed by some practi- 
tioners. This is now avoided as much as possible, and the treat- 
ment adopted in its place has been denominated that by extinction. 

All practitioners, however, do not equally dread the occurrence 
of salivation. Some there are who do not believe that it is injuri- 
ous, nor do they imagine that it is of advantage ; at least their 
method of administering mercury would go to corroborate this 
assertion. Thus these practitioners, in the treatment of the syphil- 
ida, are not afraid to give the proto-iodide of mercury in doses of 
three grains and more in the day. They know that it may pro- 
duce a certain degree of salivation, and as they can arrest it by 
suspending for awhile the use of the mercury, they administer 
large doses. But if they suspend the mercury, they arrest the 
treatment. Now, in my opinion, this is a great inconvenience, 
and a cause of failure and relapses. This I have already stated. 
Salivation, therefore, whether voluntarily or involuntarily pro- 

* Grappin, These de Paris, 1846. 



THERAPEUTICS. SH 

duced, is unfavorable in both the points of view I have indicated, 
for it may prove injurious by the disorders directly caused by the 
mercury, and because it compels the practitioner to interrupt a 
treatment, the success of which greatly depends upon the contin- 
ued employment of its means. However, there are certain cases, 
but very rare, which would seem to justify the practitioner in 
provoking a slight salivation ; but then it is for the purpose of 
combatting accidents which might rapidly compromise organs of 
great importance ; thus I have observed, that in serious cases of 
syphilitic iritis, we may derive a certain advantage from saliva- 
tion ; it then effects a derivation on the part of the mouth, which 
promptly relieves the eyes. I shall return to this subject in treat- 
ing of iritis. 

Treatment. — In the first place, salivation is to be avoided, that is 
to say, we must have a prophylaxis. I have already alluded to 
the want of success of the combinations of camphor and sulphur 
with mercury. In describing the method of Pihorel, I showed, 
also, that the combination of mercury with ammoniated lime, had 
been unsuccessfully tried in preventing stomatitis. It is better to 
prepare the patient properly as I have recommended ; blood-letting 
in certain young and vigorous subjects, cathartics and baths in all 
cases, may singularly promote the tolerance of the mercury. But 
the best prophylaxis is that based on the knowledge of the causes 
which I have already described. Sudden changes of temperature, 
and especially humid cold, must be avoided. The patient, how- 
ever, should not be closely confined in small and heated rooms. 
I have stated that the accumulation of patients who have submit- 
ted to frictions, in a small ward heated by a stove, was a deter- 
mining cause of stomatitis. Above all, the use of mercury in 
large doses should be avoided, for it is the quantity administered, 
and not its mode of administration, that especially produces sali- 
vation. If it be deemed advisable to introduce a large quantity 
of mercury into the system, we must proceed cautiously at first, 
in order to establish a kind of tolerance of the medicine. We can 
only succeed by commencing with small doses, and continuing 
them for a length of time. 

The curative treatment of ptyalism consists in the use of both 
direct and indirect means. Soothing and astringent gargles con- 
stitute the first. Experience confirms the utility of both, but at 
different stages of the salivation. The soothing, for example, are 
better adapted to the first period of the irritation. When the in- 
flammation is severe, it is even necessary to add to every six 
ounces of the gargle, be it of warm milk, barley-water, or of marsh 
mallow, ten or fifteen drops of laudanum. 

Gargles, alone, are insufficient when the stomatitis has become 
very intense, and we must then resort to local depletion. We 
may apply from fifteen to twenty leeches below the inferior mar- 
gin of the lower jaw, between the angle and the chin. While the 
leech bites are bleeding, 'it is well .to let the patient's feet be im- 
mersed in very warm water. ' At a later period we may substitute 
for the emollient applications oxycrate or lumps of ice over the 



gl2 YIDAL ON VENEREAL DISEASES. 

lower jaw. The patient may likewise introduce fragments of ice 
into the month. These means should be continued whilst the 
symptoms remain unabated, but when they begin to subside, and 
the irritation has sensibly diminished, we should resort to the use 
of astringent gargles, such as plantain water, with a certain pro- 
portion of alum, water acidulated with vinegar or a few drojos of 
sulphuric acid, a decoction of roses, of gall-nuts, or of tannin. 

The mercurial ulcerations become so indolent towards the ter- 
mination of ptyalism, that they will not heal, although subjected 
to the stimulation of the astringent gargles of which we have 
spoken. They must then be touched with caustics, such as the 
nitric or sulphuric acids, Lanfranc's collyrium, the sulphate of cop- 
per, the pierre infernale, and the hydro-chloric acid. The latter 
acid has already been much employed. It may be applied with a 
brush to the different seats of ulceration, and thus produce a de- 
cided improvement in their condition. The same effect may be 
obtained with the crayon of nitrate of silver. These caustics may 
be employed even at the commencement of the disease, in which 
case they should be applied to the parts of the gums and cheeks 
primarily affected. Stomatitis may thus be arrested, if not very 
severe, and especially if at the same time the mercury be discon- 
tinued. 

A gargle composed of one-eighth part of the chloride of soda 
has also been used with advantage. But we may meet with patients 
in whom this application will excite too much irritation ; the acrid 
character which it gives to the gargle, becoming sometimes insup- 
portable. In such cases it is better to use a proportion of one- 
sixteenth or one-twentieth in some mucilaginous vehicle. Under 
other circumstances, on the contrary, the atonic condition of the 
mercurial ulcers may be such as to require the application of the 
chloride of soda, diluted with but a very small quantity of water. 

M. Lagneau has also employed, for the same purpose, lozenges 
composed of the chloride of soda, gum and sugar, with the addition 
of some aromatic substance. Sometimes he administers these 
lozenges with the view only of removing the offensive fetor of the 
breath in persons who are subjected to mercurial treatment, and 
who are not yet salivated ; he uses them in cases where the breath 
becomes offensive from other causes. 

The internal use of opium has likewise been recommended to 
relieve salivation, but the experiments made at the venereal hos- 
pital with this medicine have not been favorable to its reputation 
as an anti-sialagogue. On this account, however, opium should 
not be absolutely rejected in cases of ptyalism. When we wish to 
diminish great irritation in the mouth, laudanum may be success- 
fully employed. 

Hunter had great faith in the efficacy of opium. He has stated 
that when the effects of mercury are felt in the mouth and 
pharynx, the application of opiated lotions to these parts is often 
of advantage. It allays the irritability, and consequently the pain ; 
it also diminishes the secretion. The following formula has been 
extolled : 



THERAPEUTICS. 313 

No. 1. ^. Caps. Papav. contus. % ss. 

Sem. Lin. f i. 

Aq. bull. I vi. 

Syr. Mel. | ii. 

No. 2. 5. Decoct, rad. Marsh mallow, J vi. 

Laud, of Sydenham. 20 to 30 m. 

Whatever may be the modus operandi of the direct means em- 
ployed to arrest salivation, as they can act only temporarily on the 
local irritation without modifying the cause producing it, we 
should, according to M. Lagneau, consider them only as accesso- 
ries to other anti-sialagogues' which have a tendency to displace 
this irritation or to render the mercury incapable of maintainihg it 
by causing it to undergo, if we can believe some authors, new 
combinations. At the head of these indirect means must be placed 
cathartics. They transfer the irritation to the intestines, and may 
thus prevent ptyalism, and their continued use is an excellent cu- 
rative means, when salivation has been produced. In the latter 
case it is an established principle that they must be administered 
much more frequently. Purgatives often promptly arrest the pro- 
gress of a salivation in the course of five or six days. Sometimes, 
however, it is not suppressed under from fifteen to twenty days. 
But even their purgatives are not without their advantage, for 
they may prevent the aggravation of the buccal irritation, even if 
they are insufficient to arrest its progress. 

It is customary to prescribe an ounce of the sulphate of soda or 
magnesia, to be taken in three glasses of chicory water, or a bottle 
of the solution of the citrate of magnesia. M. Lagneau recom- 
mends a pill of soap and aloes according to the following for- 
mula: 

^. Sapon. Offic. § ii. 

Pulv. Rhei. I i. 

Aloes. Pulv. (fine) 3 ss. 

Make into pills of one grain each, of which from three to six are to be taken 
in the day. 

Hot baths are frequently employed in cases of salivation. Their 
efficacy is explained by the cutaneous excitement diverting the vital 
forces which act too violently on the salivary apparatus, in which 
case their action may be compared to that of purgatives or other in- 
direct irritants. Foot baths may have the same effect, and may 
be used with benefit ; the latter act especially as derivatives, if 
to them we add mustard powder or two ounces of hydro-chloric 
acid. Recourse has also been had to the abstraction of blood by 
cupping, or to dry cupping, to rubefacients and dry frictions, in 
order to transfer the irritation to organs remote from the salivary 
glands. For this purpose even blisters have been used. _ They are 
especially useful when the salivation is disposed to continue very 
obstinate ; for it sometimes happens that ordinary means fail, and 
we are obliged as a last resort to employ those of a severer nature. 



314 YTDAL ON VENEREAL DISEASES. 

Blisters like the cups may be applied to one or both arms ; but the 
nucha of the neck is the place generally selected on account of its 
proximity to the parts. 

Mussa Brassavole, who wrote in 1551, believed that salivation 
was produced by mercury reaching the mouth in its metallic state. 
He recommends that the patient should constantly hold in his 
mouth a piece, or ring, of gold, in order that the mercury may 
combine with it, and thus lose its sialagogue properties. These 
experiments have been repeated by the most skilful chemists of 
our day, but they have never been able to detect a single atom of 
mercury on the gold. 

[The evidence upon this subject, afforded by the carefully-con- 
ducted researches of Dr. Samuel Wright, of Birmingham, England, 
is not without its value, confirming, as it does, the conclusions of 
Devergie and others, who have failed to detect any portion of 
mercury in the saliva of those affected with stomatitis. In his 
lectures on the physiology and pathology of the saliva, published 
in the London Lancet, Sept. 1842, p. 803, he remarks: " As far 
as my own experience is concerned, and I have operated largely, 
and with much patience, I can offer no evidence in favor of the 
presence of mercury in the saliva of people suffering from mercurial 
ptyalism. I have employed all the most eligible and delicate pro- 
cesses recommended by Christison, especially the galvanic test and 
destructive distillation, but not in one instance have I succeeded." — 

a c. b.] 

The affinity existing between sulphur and mercury having long 
since been remarked, this simple substance was early recommended 
for the purpose of arresting the progress of salivation. It is given 
in substance, in the form of lozenges. Some advantage has been 
supposed to be derived from this agent notwithstanding our igno- 
rance of its manner of acting on our. organs. Perhaps it is a 
derivative. It may also act as a stimulant to the alimentary canal, 
and by increasing the activity of the functions of the skin. M. 
Lagneau, who seems to be an advocate for the use of sulphur, 
reproaches it as well as other anti-sialagogues, with not constantly 
fulfilling the expectations of the practitioner, but as its employment 
is sometimes followed with good effects, he recommends it more 
strongly, as it is very innocent and does not prevent the simulta- 
neous use of purgatives, of gargles, and other appropriate means. 
This practitioner has seen sulphur thus administered, three times 
arrest a ptyalism during the same treatment, in a subject whose 
mouth became constantly affected by the slightest dose of* mercury. 

Pearson observed the efficacy of sulphuric acid administered as 
a beverage, a sufficient quantity being used to give it an agreeable 
acidity. M. Lagneau, who has used both the mineral and vegeta- 
ble acids, speaks of it in the highest terms. 

I have thus noticed briefly as possible most of the means which 
have been employed in the treatment of salivation, but I should 
remark that all are not possessed of the same degree of efficacy. 
Slight cauterization with hydro-chloric acid or the nitrate of silver, 
and the use of purgatives, constitute the basis both of the direct 



THERAPEUTICS. 315 

and indirect treatment. The other means are accessory, with the 
exception of local or general depletion in young and plethoric 
subjects, and when there is manifest congestion of the mouth. It 
should be well understood that first of all, the administration of 
mercury is to be suspended. 

Cholic and Diarrhoea.. — Mercurial Tremor. — At the present day 
perhaps mercury produces more frequently morbid effects upon 
the intestinal canal, than it does salivation, for it is almost always 
administered internally. 

Diarrhoea, and especially cholic, occur in certain patients after 
every dose of mercury ; and continue during the day and following 
night. This accident is more frequent in females, and is much 
more frequently observed after the administration of the proto- 
iodide, than the bi-chloride of mercury, either because the latter is 
administered in smaller doses, or perhaps on account of its more 
frequent combination with opium ; for the formula of Dupuytren 
is very much used. It is especially in cases where the mercury is 
thus administered that we observe constipation. It is not very 
rare, indeed, that hospital patients who are treated for primary 
accidents, with the pill of Dupuytren are thus affected. But this 
is an inconvenience of much less importance than diarrhoea and 
cholic; in the latter case the mercury should be either discon- 
tinued or its dose so diminished as no longer to produce abdominal 
trouble. In all cases it is better to combine it with opium. 

Mercurial tremors I believe to be very rare. I have observed 
them but in three instances, once in a gilder, and once in a patient 
who for a long time had made use of frictions. There is at present 
in my service a patient in whom this accident has followed the 
administration of mercury in baths. As facts of this kind are 
rare, and as the cases are generally wanting in details, the circum- 
stances connected with this case besides seeming to possess a real 
interest, I here insert the particulars which I have been able to 
collect in regard to this patient. 

L. (Alf.) set. 19. Admitted March 15th, 1852, into Ward 9, 
No. 1. He has several times been affected with blennorrhagia. 
The last attack was in 1848. The treatment prescribed was very 
irregularly followed. The patient suffered but little ; the inguinal 
glands were indolent. During the latter part of 1849 (L. was in 
the hospital of Dijon) the discharge ceased at the moment of the 
appearance of a cutaneous affection, which the practitioner regarded 
as psoriasis. The patierjt made use of corrosive sublimate baths 
for three weeks, one every day. The quantity used in each bath 
is unknown. 

After the tenth bath, L. felt slight pains, accompanied with mus- 
cular contractions, especially in the arms. Soon a little tremor 
followed, which was but of short duration. The patient lost his 
appetite and suffered constant cephalalgia, with profuse perspira- 
tion. There was constipation as well as considerable debility, 
without much emaciation. 

During the twenty-second bath, L. had violent attacks with 
foaming at the mouth, and was insensible for two hours. There 



315 YIDAL ON VENEREAL DISEASES. 

was convulsive rigidity of the extremities. "With returning con- 
sciousness, he was seized with a general tremor so violent as to 
render walking very difficult. Five or six days afterwards, the 
patient's condition began to improve, and in the course of three 
weeks, the legs and arms alone remained affected with the tremors. 
He then left the hospital at Dijon. His disease diminished under 
the influence of simple baths ; the tremors became intermittent ; 
he rarely, however, passed an entire day without an attack, having 
from one to twenty during the day. (Their duration was gener- 
ally from three to ten minutes.) Stimulating drinks, and strong 
mental emotions, exerted an influence in producing their attacks. 
The baths of corrosive sublimate effected no change in the con- 
dition of the cutaneous affection, which was not cured until two 
months afterwards. 

Notwithstanding this affection of the nervous system, the pa- 
tient indulged in sexual intercourse, and contracted a chancre, for 
which he came under our care. This chancre, of a serpiginous 
form, was very painful; he had also intense cephalalgia. The 
tremor, confined to the limbs, diminished under the influence of 
baths and mild purgatives. Of course I refrained as much as 
possible from the use of mercury when I commenced the general 
treatment. The above is an example of epileptiform mercurial 
tremors. 

As to the morbid affections of the skin and the kidneys, de- 
scribed in some books as the results of mercurial treatment, I am 
not aware that such have been carefully observed, and if they 
really deserve to be called accidents. If the reader have noted 
our remarks upon the morbid effects of mercury, he will have be- 
come convinced that this medicine produces those of a grave char- 
acter only when it has been improperly administered. By avoid- 
ing those proceedings which suddenly introduce into the system 
too large a quantity, as, for example, frictions, and by moderating 
the doses for internal use, we may almost always prevent, not 
only the slight inconveniences of the mercurial treatment, but the 
morbid effects which may be regarded as the accidents of this 
treatment. 

In conclusion, briefly, we would state, that the bi-chloride in 
small doses for the primitive accidents, the proto-iodide in little 
larger doses for the secondary accidents, are the two forms under 
which mercury renders most service in practice. 



IV.— IODINE. 

The introduction of iodine into the treatment is a recent and 
most happy event. It may, therefore, be of some interest to know 
how it occurred. In 1821, Coindet announced that an addition 
had been made to our therapeutics of a new resolvent, a precious 
discutient, viz., iodine. At the same time, a revolution was going 
on in England against mercury ; and France became converted to 
the opinions promulgated by Broussais. Mercury became unpop- 



THERAPEUTICS. 317 

ular, not only because it failed to cure venereal diseases, but be- 
cause it provoked or aggravated the consecutive accidents. The 
innovators, therefore, proscribed mercury from the therapeutics 
of syphilis, and employed only soothing remedies, and anti-phlo- 
gistics, in other words, the means authorized by the physiological 
school. But the inefncacy of these means, in many cases, soon 
became apparent. Mercury they would not reinstate, for that 
would be a recantation, but they sought a new specific. Iodin€ 
arrested their attention, and to this remedy they resorted. Thus, 
in 1823, we find Eichond-Desbrus prescribing this metalloid in 
cases of bubo and blennorrhagia ; in England the advocates of 
the same doctrine entered the same path, and iodine was pro- 
claimed an anti-syphilitic. 



V.— IODIDE OF POTASSIUM. 

Pure iodine is too difficult to manage, its effects are too diver* 
sified, too opposite even, for symptoms of intoxication are some- 
times observed after very small doses, whilst in other instances 
very large doses may be taken with impunity. It has, there- 
fore, been deemed advisable to combine this metalloid with other 
substances, and Buchanan, of London, was the first to unite it with 
amidon. He obtained an iodide of amidon, which was employed 
with the iodide of iron, both in France and London, as an anti- 
strumous, anti-syphilitic remeay, but this was done without 
method, and, it must be confessed, not with full confidence. 
Then (1836) appeared the famous lectures of Wallace .* This was 
the inauguration of the iodide of potassium as an heroic remedy 
against syphilis. One hundred and forty -two cases of venereal 
disease attested the virtues of the new medicine. And we must 
not omit here to mention that Wallace employed a formula which 
even to this day passes for one of the best. It is as follows : 

^ . Iod. Potass. 3 ii. 
Aq. | viii. 

A tablespoonful to be taken four times in a day. 

In this manner the patient takes nearly half a drachm of the 
iodide in the day, which quantity, it was asserted, in the majority 
of cases, is sufficient to overcome the worst cases of syphilis. 

Soon Wallace had followers both in Germany and France. 
Cullerier, M. Eicord, and other practitioners still, experimented, 
and extolled the iodide of potassium in such a manner as to excite 
a real enthusiasm. They did not, however, go so far as to pro- 
scribe mercury, but the latter was compelled to co-operate with 
the new agent, and M. Eicord took upon himself to make the fol- 
lowing distinction in the treatment, viz., tertiary accidents were to 
be treated by the iodide of potassium, and the secondary by mer- 
cury, This gave rise* to objections, which I shall make known. 

* The Lancet, March, 183C. 



318 VIDAL ON VENEREAL DISEASES. 

The iodide of potassium has many arguments in its favor : first, 
the truly admirable cures obtained by it, in a short space of time 
(as I shall hereafter show), the facility of its administration, and 
the absence of all real danger, which is not the case with pure 
iodine and the other preparations. Further, the iodide of potas- 
sium being very soluble in water, it may be taken in all kinds of 
vehicles and drinks. Its action being infinitely less irritating than 
that of pure iodine, it may be administered in very large doses : 
a practitioner in Paris, indeed, having given an ounce, and even 
more, in a day. It may be used in as small a quantity as one and 
a half grains. There are but few substances capable of being ad- 
ministered according to so great a variety of formulas, and under 
so many different circumstances of age, taste, convenience, and 
even caprices of the patient. The dose may also be proportioned to 
the degree and nature of the accidents ; for I shall, in another place, 
show that the iodide of potassium may fulfil a double indication. 

I shall not here insert all the different formulas which have been 
proposed for its administration, for, as has been stated, they are innu- 
merable. I shall mention only the principal and most important. 

M, Eicord employs the following : 

fy. Iod. Potass, gr. iss. 
Syr. Papav. | i. 
Aq. dist. | iii. * 

The dose is to be increased every five days about eight grains, until we 
reach one and a quarter ounces in the day, a quantity which should rarely 
be exceeded. 

A year afterwards, the same practitioner taught that we might 
commence with fifteen and even thirty grains a day, and that the 
patient would always tolerate two and two and a quarter ounces 
in the day. 

Finally, in his notes to the second edition of Hunter, M. Eicord 
observes : " When tertiary accidents alone exist, the most success- 
ful treatment consists in the use of the iodide of potassium. We 
may commence with forty -five grains in the day. This is to be 
taken in three doses, in three glasses of the decoction of sarsapa- 
rilla, of hops or soapwort. Every five days the dose is afterwards 
to be increased from fifteen to thirty grains, which I rarely exceed." 
The two following formulas shows how large is the quantity given 
by M. Puche : 

HOSPITAL FORMULA FOR THE SOLUTION OF THE HYDRIODATE 
OF POTASSA. 

3 . Iod. Potass. § iii. 
Aq. 5 xii. 

Cochineal, q. s. f. rose-colored solution. 

To be used in cases of chronic syphilis and tertiary symptoms, such as 
ecthymatous ulcerations, tubercles, periostitis, exostosis, and caries. 
Dose, from one to four ounces in a pint of bitter or sudorific tisane. To 
be taken at six different times at regular intervals. 






THERAPEUTICS. 319 

SYEUP OF IODIDE OF POTASSIUM. 

$. Iod. Potass. 3v. 

Anisette of Bordeaux, | iss. 

Syr. Sacch. § xiv. 
Cochineal, q. s. 

Dose, from one to four ounces a day in half a pint of cold water. The 
whole to be taken in four doses at regular intervals. 

N.B. — Tlie dose of the hydriodate of potassa in this syrup may be in- 
creased to three ounces. 

I employ the iodide of potassium both as a tonic and an anti- 
syphilitic. I never give more than fifteen grains to fulfil the first 
indication, and rarely exceed one drachm for the second object. 
Let me explain : I believe that almost all cases of syphilis may be 
sucessfully treated by mercury, if this medicine be properly man- 
aged ; but sometimes the system is antipathic to it, and then, 
instead of producing curative, it produces morbid effects : thus, 
patients who are excessively debilitated, cannot be treated with 
mercury, which evidently depresses the vital forces, since it is 
called a hyposthenisant. I give, in these cases, the iodide of 
potassium, in doses from one to one and a half and fifteen grains, 
but never in larger quantities. With these doses I do not propose 
to act upon the diathesis ; I aim not directly at the virus, but I 
endeavor to act upon the system, to strengthen it, and to place it 
in the best possible condition to resist the intoxicating agent, and 
at a later period to tolerate the use of mercury. The iodide of 
potassium is not, therefore, a specific, and when it cures, it does so 
indirectly, by a contre-coup. The stomach regains its tone under 
the influence of these minute doses, the appetite becomes keen, 
nutrition active, the strength re-established, and it is not uncom- 
mon for the patient to acquire a certain embonpoint. But some- 
times the venereal affection continues obstinate. If the case be 
one of the superficial syphilides, it does not disappear ; it may 
even become aggravated ; now is the time to interpose the use of 
mercury, which may be employed alone, if the patient's strength 
be restored, or its use may be conjoined with that of the iodide of 
potassium. At a later period of the disease, when the fibrous, 
osseous, and deeper-seated tissues, are involved, it is of great im- 
portance to give specific dose^s, those which act directly on the 
malady. We may commence with half a drachm, and the same 
week increase the dose to one or one and half drachms a day. The 
following is my formula : 

* 
3. Iod. Potass. § ss. 
Aq. dist. 3 viii. 

A tablespoonful to be taken morning and evening in a glass of hop or 
soapwort tisane. The dose may be gradually increased to six spoonfuls, 
and as, according to this formida, each spoonful contains fifteen grains 
of iodine, ive give, tlierefore, one and a half drachms a day. I do not 
ordinarily prescribe the latter quantity. 



320 VIDAL OX VENEREAL DISEASES. 

At the Hopital du Midi, the bottles containing the iodide are 
marked with transverse lines on their sides, so as to make divis- 
ions, each of which contains a tablespoonful of the solution, or 
fifteen grains of the iodide ; the whole bottle contains eight spoon- 
fuls. I have them made containing sixteen spoonfuls. 

It is evident that the iodide of potassium, in a large dose, acts 
directly upon the diathesis ; first, by the beneficial modifications 
which it produces on the disease in an incredible short space of 
time, and before the general health appears to be the least im- 
proved ; 2d, by the failures which occur when less than fifteen 
grains have been administered, and the success obtained by in- 
creasing the quantity in precisely the same cases. I have known 
a young literary character, who had a chronic ulceration at the 
base of the tongue sufficiently deep to lodge the extremity of the 
finger. This patient was treated without success for six months 
with the iodide, which was not given in larger quantities than 
eight grains in the day. He had been treated in the country. On 
his arrival at Paris he came under my care, and I commenced 
with thirty grains a day ; this quantity was increased to one 
drachm a day during the first week, and in thirty days the ulcer 
had completely healed. 

[There can be no question that the iodide of potassium is often 
administered in doses too feeble to derive all the benefits that 
this remedy is capable of affording. Dr. Graves recommended 
thirty grain doses three times a day. During our recent visit to 
London we saw some inveterate cases of syphilis, which had re- 
mained for many months in the hospitals, and we ascertained that 
they were taking but two grains three times a day ! But can the 
iodide of potassium cure even the tertiary stages of syphilis ? We 
believe not, and such we find is the opinion of many experienced 
practitioners whom it has been our privilege to meet not only in 
Europe but our own country. As remarked by Sir Benjamin 
Brodie (Lect. in Lond. Lancet, Feb. 17, 1844), " You may remove 
slight symptoms by giving it for a time, and severe symptoms, by 
exhibiting larger doses ; but in the latter case, so far as I have 
seen, it does not make a permanent cure, for the symptoms return 
again. As a prophylactic, it is not to be compared with mercury." 

In a letter recently received from Mr. Langston Parker, he 
says, " I believe the curative effects of iodide of potassium have 
been over-rated. It suspends disease, but often fails to cure. 
Iodic cachexia, which is common from its prolonged use, is worse 
than any symptom which mercury produces. I have known it 
taken by patients for three, seven, and in one case (a surgeon) ten 
years ; it always kept the disease in check, but when discontinued 
the symptoms became worse." 

In this view of the subject, as we have been personally assured, 
Drs. Mussey, Willard Parker, and John Watson, coincide. At the 
Dublin Lock Hospital, we were informed, that in cases of much 
debility, they employed a combination of iodine and soda instead 
of the potash. It is administered in ten-grain doses three times 
a day. For a full account of the evidence in favor of iodine 



THERAPEUTICS. 321 

and its compounds, we would refer the reader to the elaborate 
article of Dr. Hocken in the Ed. Med. and Surg. Jour. vol. lxi., 
and the work of Dr. Dunglison on New Remedies, last edition. 
— G.C.B.] 

The iodide of potassium may also produce a prophylactic effect ; 
it may assist the mercury in preventing the formation of the last 
stages of syphilis. Thus I often give it in small doses, after a 
complete mercurial course, in the treatment of primitive or sec- 
ondary accidents, which have exhibited an unusual degree of ob- 
stinacy, especially when the patient is feeble. I then dissolve the ■ 
iodide in the syrup of fumitory, or of burdock, of which a table- 
spoonful is to be taken two or three times in the day in a glass of 
hop tisane. 

I have already shown that the use of the iodide is not to be 
restricted to the tertiary accidents, but that it has been used dur- 
ing every period of the anti-syphilitic treatment. If we examine 
the list of cases reported by Wallace, we shall find that it con- 
tains those of secondary accidents, and of late this medicine has 
been proposed not only in the second stages of syphilis, but even 
in the first, the so-called primitive accidents. MM. Payan* and 
Bazinf have published facts, going to show that this powerful 
agent may in certain of these cases produce happy effects. 

I am far from wishing to dispute these facts, for I possess those 
of an analogous nature, having experimented with this medicine 
in every stage of syphilis. I have seen chancres and secondary 
cutaneous affections cured during the employment of this remedy ; 
but its therapeutic action has never appeared so prompt and well 
defined, as when it is employed in the treatment of very chronic 
tertiary affections ; in fine, I have never been able to satisfy my- 
self beyond a doubt of its efficacy in the other forms of the dis- 
ease. In these new applications the cure may doubtless be re- 
ferred to the iodide, but we should not overlook the efforts of 
nature, for in almost all a sufficient time elapsed to permit such 
a result. 

[The recent memoir of M. Melseus " On the Employment of 
Iodide of Potassium as a Remedy for the Affections caused by Lead 
and Mercury" has attracted considerable attention. He main- 
tains that, after its absorption into the blood, it combines with the 
metallic poison, and forms with it a new and soluble salt — liberates 
the poison from its union with the injured part — dissolves it out, 
so to speak, and sets it afloat in the circulation. Thus free, as 
supposed, in the form of a double iodide of mercury and potas- 
sium, it escapes through the kidneys, in combination with any ex- 
cess of iodide of potassium that may be present, and both remedy 
and poison are cast out together. Dr. Wm. Budd has given an 
analysis and translation of this memoir in the Jan. Number (1853) 
of the Brit, and For. Med. Chir. Review, and another notice of it 
by Mr. Parkes, Clin. Prof, in University College, may be found in 

* Vide Journal de la Societe de 3fedecine de Bordeaux, 1S44. 
\ Gazette des Hbpitaux, 1843. 

21 



322 YIDAL ON VENEREAL DISEASES. 

the April Number of the same Journal. Dr. Budd has appended 
numerous remarks corroborating the views of M. Melseus. Some 
twenty years ago Mr. Judd, in his Treatise on the Venereal, p. 
564, thus remarked : " After mercury has produced ptyalism, 
broken down the general health, and begun to bring scrofula into 
action, iodine then appears to act in a far more salutary way than 
in cases wherein no mercury has been taken. Is it not possible, 
nay even likely, that under these circumstances the iodine (espe- 
cially the hydriodate of potash) being taken into the system, forms 
an Hydriodate of Mercury in the living blood ? Seeing that Bin- 
iodate of Mercury, in a solution of Hydriodate of Potash, formed a 
crystalline triple salt, I attempted to procure similar crystals from 
the blood after a course of mercury and Hydriodate of Potash, 
but failed." He then resorted to other experiments, from which 
he concluded that both mercury and iodine were present in the 
blood. The perusal of Mr. Judd's remarks upon the subject has 
satisfied us, that to him is due the credit of first promulgating 
the views now broached by M. Melseus. To those engaged in the 
investigation of this subject we would recommend the perusal of 
the interesting Essay of our esteemed friend Dr. J. W . Corson, 
entitled " Cases testing the Iodide of Potassium, as an Antidote to 
the Injurious Effects of Mercury, and corroborative of ike Experiments 
of M. Melseus" published in the ISTew York Journal of Medicine 
and Collateral Sciences, Sept. 1853. — Gr. C. B.] 

ACCIDENTS ATTRIBUTED TO THE IODIDE OF POTASSIUM. 

Strictly speaking, these are not true accidents ; they are, in the 
majority of cases, pathogenetic effects which subside on the dis- 
continuance of the remedy, and which never assume a serious 
importance. These effects are manifested on the mucous mem- 
brane of the nose, eyes, mouth, stomach, and intestines ; they may 
likewise be observed in the urinary organs, the skin and nervous 
system. 

The most prompt and common effect is upon the pitulary and 
ocular mucous membrane. The majority of patients are attacked 
at the commencement of the use of the iodide of potassium, with 
coryza which is sometimes very acute. At the same time well- 
marked symptoms are observed of catarrhal opthalmia, with more 
or less decided serous chemosis and oedema of the eye-lids ; some- 
times this amounts but to a simple redness. It is rare for both 
mucous membranes to become the seat of a muco-purulent secre- 
tion. I have seen a patient at the Eopital duMidi, whose conjunc- 
tiva at first became tumefied, after which followed a sanguineous 
effusion into the cellular tissue of the eye-lids, which absolutely 
discolored them like an ecchymosis. The patient, seen at a dis- 
tance, seemed to wear large glasses of a violet blue color. I treated 
him for a chronic engorgement of the testicle ; he was very much 
debilitated ; he took only fifteen grains of the iodide of potassium. 

Salivation frequently occurred ; it resembled that of pregnant 
women, consisting of a kind of regurgitation of a saline saliva, of 



THERAPEUTICS. 323 

a metallic and bitter taste. To a certain extent it was like a mer* 
curial salivation, for in some patients an erythematous, cedematons 
tumefaction of the gums occurs ; but this congestion never amounts 
to an inflammation as in the case of a mercurial ptyalism. Fur- 
ther, it is never accompanied with ulcerations of the lining mem- 
brane of the mouth ; it has neither the peculiar odor nor fetor of 
the breath. According to M. Payan, chemistry has been able to 
detect the presence of the hydriodate of potassa in the saliva.* 

In the majority of cases the digestive organs tolerate well the 
use of the iodide of potassium, and we often observe an increase 
of the appetite, especially when it is administered in small doses ; 
but sometimes patients complain of a pain and uneasy sensation 
in the region of the grand cul-de-sac of the stomach. This pain 
sometimes resembles that of pleurodynia. This did not escape 
the attention of Wallace ; he speaks of a cough and difficulty of 
respiration. But the pain in these cases is more profound than 
in pleurodynia. In certain cases the thirst is increased, although 
generally the appetite alone is augmented, and nutrition promoted, 
so that the patients soon acquire a degree of embonpoint. Some- 
times, but more rarely, vomiting and diarrhoea are observed. M. 
Payan mentions the case of a scrofulous child, in whom the iodide 
of potassium produced a chronic gastro-enteritis, which required 
nearly a month for its removal. A chronic gastro-enteritis, how- 
ever, which soon subsides, I must say is an accident of very little 
importance, and I would add, that M. Payan attributes the dis- 
ease in this case to faulty nutrition. 

Symptoms of bronchitis have also, though rarely, been noticed. 
Certain affections of the skin may also appear ; these most gener- 
ally assume the form of acne, and ecthyma, with very small pus- 
tules. I treated a patient in town whose face was covered with 
an eruption which resembled the first appearances of variola, and 
this occurred on the next day after the commencement of the 
administration of the iodide of potassium, if we exceeded fifteen 
grains at a dose. It is still more rare to meet with the spotted 
malady of Weslohl. M. Payan cites an example in his memoir. 
The patient was of a lymphatic temperament. He had taken the 
iodide for two months. Spots appeared on both legs resembling 
ecchymosis resulting from a contused wound. 

The urinary organs are very much affected in certain subjects, 
and the secretion of urine greatly augmented in the majority of 
cases. M. Payan has seen a patient who voided seven pounds of 
urine in twenty -four hours. He took eighteen grains of the medi- 
cine in the day. It should be stated, however, that this patient 
had a chronic affection of the bladder, and perhaps of the kidneys. 

The circulation, apparently, is not affected. According to the 
Italian school, the frequency of the pulse is diminished. M. Payan 
assures us, on the other hand, that it is accelerated. The cases of 
hemorrhage, which have been very rarely observed, have been 

* Vide a work by this physician on the employment of the iodide of potassium, 
<fcc., p. 221. 



324 VTDAL Otf VENEREAL DISEASES. 

regarded, sometimes as passive, sometimes as active. I have seen 
a patient affected with nasal hemorrhage, after having taken thirty 
grains of the iodide in two days ; he was excessively feeble. As 
to the nervons system, says M. Eicord, some patients experience 
what is called an iodic intoxication, and which is characterized by 
an impairment of the voluntary movements, twitchings of the 
mnscles, a sense of weight in the head, a kind of mental inactivity, 
and occasionally by slight disturbance of the intellect. 

u The iodide of potassium has been accused of producing atro- 
phy of the glands, particularly the mammary, and the testicles. 
It is indeed one of the most powerful resolvents with which I am 
acquainted, but it affects only the diseased parts, the atrophy of 
which it may sometimes produce, but this is not its only oper- 
ation."- 



YL— IODIDE OF IRON. 

The iodide of iron is sometimes employed in the treatment of 
the last stages of syphilis. According to M. Bouchardat, the phy- 
sicians at the Hotel-Dieu have for ten years been accustomed to 
administer this heroic agent in large doses, for the removal of syphi- 
litic accidents of long standing, and which have resisted the prepa- 
rations of mercury. 

I am satisfied that the iodide of iron is a therapeutic agent of 
certain power ; but I am confident that in cases where mercury 
has proved ineffectual, the use of the iodide of potassium will be 
followed by the greatest success. 

The iodide of iron is particularly adapted to cases where a de- 
cided syphilitic cachexia exists, and a state of anemia, or of debil- 
ity complicated with scrofula. M. Baumes has observed, in cases 
of imperfect plasticity of the blood, and of obstinate ulcerations, 
the most prompt and remarkable effects from pills of the proto- 
iodide of iron. The formula is M. Bouchardat's formula : 



^. Iod. I iiss. 
Fer. 3 ii- 
Aq. § iiiss. 

Subject tlie whole to a temperature of 60°, until the liquid is discolored- ; 
pour off, and rapidly evaporate in an iron mortar. Wlien the water is 
nearly evaporated^ add : 

Mel. 3& 
Pulv. G-um. and Marshm allow, q, s. 

Make one thousand pills, each of which will contain about one and a half 
grains of the proto-iodide of iron. Dose, four, to be gradually increased 
to twenty and thirty a day. 

This is a very convenient form for administering the proto-iodide 
of iron. But it should not be forgotten, that the patient will not 

* Notes to Hunter, 2d ed. 



THERAPEUTICS. 325 

tolerate tlie quantity here indicated, except when the salt contains 
red iodine in a tree state. The physicians at the Hotel-Dieu have 
often remarked to M. Bonchardat, that they could not administer 
the same quantities to patients in private as in hospital practice. 
This chemist attributes the difference to the presence of free iodine 
in the pills made by ordinary chemists. According to him, this 
inconvenience may be obviated by the following formula : 

]£. Proto-iodid. Fer. 3 iiss. 
Carb. Pot. 

Mel. aa gr. 1 J. 

Pulv. Gum. and Marshmallow. q. s. 

Make one hundred pills. From one to ten to be taken in the day. 

"What answers still better, is not to increase the doses of the 
proto-iodide, and for the reason, too, that it is necessary to act 
upon the system a long time before a cure can be really effected. 

I employ most generally the syrup made according to the fol- 
fowing formulas : 

3. Proto-iod. Fer. 3 if 

Syr. Sacch. § xvi. M. 

Dose from five to six tablespoonfuls in the day. 

^ . Syr. Sudorif. § xvi. 

Proto-iod. Fer. 3 i. M. 

Dose, two tablespoonfuls daily ; may be increased to six spoonfuls. 



VII.— GOLD, SILVER, AND PLATINA 

Gold in the form of powder, or combined with oxygen, anti- 
mony, silver, or amalgamated with mercury, has been employed 
as an anti-syphilitic. Ucay, in his Nouveau traite de la maladie ve- 
nerienne (1699), remarks : " The virtues of this remedy cannot be 
too highly praised." Ucay was not the only admirer of this reme- 
dy at this epoch ; silence, however, soon usurped the place of 
these pompous eulogies, and it became buried in complete oblivion. 
At a later period (1811), Chrestien prescribed gold as a new reme- 
dial agent in the treatment of venereal and lymphatic affections. Serre 
(of Montpelier) experimented with silver, and platina. Chrestien 
employed especially equal parts of the hydrochlorate of gold and 
of soda, in the form of powder ; he also made use of the oxide pre- 
cipitated by tin or potash or metallic gold, in a state of minute di- 
vision. " These three preparations succeeded completely, no mat- 
ter what the nature of the venereal symptoms for which they 
were prescribed."* The powder was administered according to the 
method of Clare, by making frictions on the gums, the internal 

* Lagneau, t. ii., p. 193. 



326 VIDAL OIST VENEREAL DISEASES. 

surface of the lips and on the tongue. Chrestien also employed 
the following pills : 

^ . Hydroehlor. Aur. et Sod. gr. i. 
Ext. Daph, Mezer, gr. xii. 

Syr. Simp. q. s. f. pill 15. 

Dose, one in the day ; to be gradually increased to three or more daily. 

Gold has always retained its advocates at Montpelier, especially 
with the members of Chrestien's family. Experiments have been 
made, with every precaution, at Paris, by M. Legrand, and at 
Toulon, by M. Eeynaud. Eemark how it has been employed and 
judged by the latter surgeon. I will afterwards mention the 
opinions formed of this agent by some other writers on syphilis, 
and, in passing, will also allude to their estimate of silver and 
platina. 

M. Eeynaud used the same combination as did Chrestien : one 
grain of the salt and two grains of the iris powder, or lycopodium, 
moistened with water and alcohol so as thoroughly to mix ; the 
whole being divided into twelve equal parts. One of these was 
rubbed on the tongue and internal surface of the cheeks every 
morning. The patient moistened the right index finger with 
saliva, dipped it into the powder, and made frictions on the tongue 
from five to ten minutes ; the end of his finger was thrust against 
the cheeks. The latter point is selected for the frictions, if from 
any cause it cannot be made upon the tongue. They may be 
used upon the gums, but then it would be difficult to guard the 
teeth against the action of the gold, and to prevent the disagree- 
able dark color which it produces on their necks. A copious se- 
cretion of saliva follows, this should be entirely swallowed, as it is 
loaded with particles of the salt. 

After this first series of frictions, M. Eeynaud resorted to a sec- 
ond, dividing the same quantities of the medicine into ten parts, 
and afterwards a third series, the powder having been divided 
into eight parts, a fourth into seven, a fifth into six, a sixth into 
five, a seventh into four, and the eighth series into three parts. In 
the more inveterate cases, he made several experiments with the 
third and fourth divisions, so as nearly always to administer more 
than Chrestien, and sometimes to reach as high as from twelve to 
fifteen grains of the auriferous salt. According to M. Eeynaud, from 
six to nine series of frictions were ordinarily required, in other words, 
from six to nine grains of perchloride of gold and soda were used. 
Often, especially in the worst cases, this practitioner conjoined the 
use of the oxide of gold in the form of pills, which were combined 
with the extract of the bark of mezereum, but most commonly 
with the extract of cicuta, or of the woody nightshade, in the 
proportion of one grain of the oxide of gold, to nine grains of 
either of the extracts which was made into ten pills, each contain- 
ing a tenth of a grain of gold. Two of these were given in the 
day, morning and evening, and the latter either an hour before or 






THERAPEUTICS. 327 

an hour after eating, in this manner from eight to ten or twelve 
grains of the oxide of gold were administered 

Tisanes of soapwort, of chicory, or sarsaparilla, are prescribed 
as accessory means. Of course proper attention to hygienic meas- 
ures is to be observed. 

M. Eeynaud remarks that he has never observed the disorders 
of the mouth and the gastro-intestinal affections which some 
authors have attributed to the influence of the preparations of gold, 
and he has employed them at least in a hundred instances. Fre- 
quently they produce no appreciable effect upon the system, some- 
times they give rise to a little general excitement, and in a few 
cases only, is this excitement accompanied by a slight cephalalgia 
or febrile reaction, which the temporary cessation of the remedy 
causes soon to disappear. M. Eeynaud observes in conclusion, 
that almost alivays, under the influence of this treatment, he has 
seen the tertiary accidents of the syphilis gradually diminish, and 
finally become > completely cured.* 

It will be remarked that I have not commenced the exposition 
of the opinions entertained in regard to the efheacy of gold, with 
any expression which can be regarded as malevolent. It has 
been my desire, rather, to give the views of an author, who may 
be regarded as its advocate. But I cannot refrain from remarking 
that M. Eeynaud is also a great partisan of the iodide of potassium, 
a remedy which, as is known, overcomes the same accidents which 
M. Eeynaud seeks to combat with the preparations of gold. The 
great advantages attributed by Chrestien to the latter aroused the 
attention of the Societe de Medicine, and Cullerier (the uncle) was 
charged to make experiments with them at the Hopital du Midi. 
These were not favorable to what was then called the new method. 
Thirteen patients were submitted to this treatment, and thirteen 
entrusted to the vis medicatrix naturae. The lesions in all were 
the same, and the results were identical.! According to M. Ei- 
cord, gold has always been ineffectual as a general method in the 
treatment of primary affections, and in that of the general con- 
secutive accidents, it is medicine of a most doubtful reputation. 
The majority of cases cured by this remedy are far from being in- 
contestible cases of syphilis, and when it has been administered in 
those of an unquestionable character, after the use of other means 
and of mercury in particular, it proves, according to M. Eicord, 
not the virtues of the new medicine, but the advantages of suspend- 
ing for awhile an injurious treatment. 

The preparations of silver in all their forms, and after the indi- 
cations pointed out by M. Serres (of Montpelier), have seemed to 
M. Eicord still more uncertain than those of gold, both in the 
treatment of primary and of confirmed syphilis. They were ad- 
ministered at first in small quantities, and gradually increased to 
the enormous doses of from fourteen to sixteen grains daily. M. 
Eicord observes that these doses produced only irritation of the 

* P. 398. 

\ Vide, the detail of experiments in tome ii., p. 195, et suiv, of M. Lagneau. 



328 VIDAL ON VENEREAL DISEASES. 

digestive organs, which rendered it necessary to discontinue its 



use. 



M. Cazenave and Biett experimented with the preparations of 
gold. According to these practitioners, the results have always 
been so doubtful as to give them but little confidence in the value 
of these agents. As to the preparations of silver, in twenty cases 
treated with the cyanuret, the chloride, iodide, and the phosphate 
of silver, in none were they crowned with success. But, Biett and 
M. Cazenave did not treat the primitive symptoms which may dis- 
appear under almost every form of treatment, but their cases were 
those of secondary accidents, those which are called symptoms of 
confirmed or constitutional syphilis. 

It is already apparent that the experiments of Cullerier, Biett, 
MM. Kicord and Cazenave, are far from according with those of 
Chrestien. To these practitioners may be added numerous others, 
who have arrived at the same conclusions. M. Payan having 
examined these facts and opinions, thus concludes : " The treat- 
ment with gold cannot be established as a general method; it 
should be reserved, — 1st, for those cases in which mercury has 
failed ; 2d, where a decided intolerance of the mercurial prepara- 
tions forbids its use ; 3d, for those where the inefficiency of mer- 
cury is to be attributed to a strumous complication ; 4th, for those 
where the symptoms depend less on syphilis than on a mercurial 
hypersaturation which may engender accidents perfectly analo- 
gous to those of tertiary syphilis." 

For my own part, I believe that our therapeutics are not so rich 
as to permit us for a slight cause to reject any means, especially 
when accompanied with the honorable testimony which has been 
awarded to gold ; but it will be remarked that those who wish to 
retain in practice the preparations of gold, have especially em- 
ployed it towards the latter stages of the disease, after mercury 
has been sufficiently used, or after it has failed. Now this is the 
period of the disease, during which, at the present day, the iodide 
of potassium is chiefly used, the advantages of which cannot 
be questioned. What then remains for the preparations of 
gold? The cases alone which are refractory to the iodide of 
potassium. 

VIIL— DOUBLE SALTS. 

In speaking of the iodurets, I have already alluded to a double 
salt, employed by M. Puche, viz., the iodhydrargyrate. Others 
were used very anciently ; that which has been handed down to 
us, and which has always maintained a certain degree of reputa- 
tion, is the soluble mercury of Hahnemann. M. Cazenave goes so 
far as to say that it is one of the most useful preparations in the 
treatment of the syphilitic eruptions. It is of easy management 
and toleration, which renders it particularly adapted to delicate 
and feeble subjects. The activity of soluble mercury is not great, 
but it suffices in cases of superficial eruptions ; and in those of long 



THERAPEUTICS. 329 

standing, it may perhaps be used with advantage. In severer 
cases it is better to resort to the proto-iodide of mercury. 
The soluble mercury of Hahnemann is composed of 

92.2 Protoxide of Mercury. 
1.9 Ammoniac. 
5.9 Nitric acid. 

As this salt is readily decomposed, Hahnemann preferred the 
form of powder, after the following formula : 

POWDER OF THE SOLUBLE MERCURY OF HAHNEMANN. 

Soluble mercury. 
Opium, aa. gr. i. 

Powder of tragacanth or liquorice, 5 to 10 grains. 

M. Cazenave employs the following pills : 



Soluble mercury: 
Thridace, aa. J ss. 

Make forty pills : one to be taken morning and evening. M. Cazenave is 
reported to have given as many as four daily. 

IX.— SUDORIFIC WOODS. 

These woods, which at one time had so great a reputation, have 
now fallen into the most complete disrepute. Even guaicum, 
which nearly dethroned mercury, is now regarded but as an acces- 
sory means, or as a vehicle for other remedies. 

We know that this wood was first brought from St. Domingo 
by the Castilians, who used it medicinally. Leonard, Poll, and 
especially Ulric of Hutten, who owed it a certain debt of grati- 
tude, extolled it beyond measure. 

The following tisane of guaiac is still employed conjointly with 
the preparations of mercury : 

^ . Gruaiac, (rasped), 3 iv. 
Aq. Com. 2 quarts. 

Macerate twelve hours, reduce it to one half then add: 
Had. Grlycyrrh. § i. 

Sarsaparilla is still used in the form of decoction during the 
administration of mercury, especially in the treatment of the con- 
secutive accidents. With some practitioners, it is from custom 
rather than from any conviction of its utility, that it retains its 
place. It enters besides into the composition of certain tisanes and 
syrups, as we shall hereafter show; as for example, in the tisane 
of Arnoud, and the syrup of Cusinier. 

The simple sarsaparilla tisane is prepared according to the follow- 
ing formula : 



830 VIDAL ON VENEREAL DISEASES. 

3- Sarsapar. § iv. 

Aq. Com. 2 quarts. 

Macerate twelve hours, and afterwards bruise the roots in a marble mor- 
tar, and reduce to one half the quantity. 

The tisanes of China root, of sassafras, and other sudorific woods, 
are prepared in the same manner. The roots of lobelia and astra- 
galus are no longer used. As to the soapwort, its leaves are much 
used at the present day, in the preparation of a tisane in which the 
iodide of potassium is dissolved. 



X.— COMPOUNDS, PARTLY MINERAL, PARTLY 
VEGETABLE. 

If with an unprejudiced mind we carefully examine the majority 
of these compounds, we shall soon become convinced that their 
efficacy depends on the mineral substance they contain. Thus, 
the syrup of Cusinier alone possesses no efficacy, but united with 
corrosive sublimate it then becomes a powerful remedy. The 
tisane of Rittmann is of therapeutic value only on account of the 
proto-chloride and the sulphuret of mercury that it contains ; that 
of Feltz is due to the sulphuret of antimony, and thus it is with all 
the tisanes, all the compound syrups, and all the robs ; when uncom- 
bined with other agents they have but a moderate action. 

I give the formulae for two of the compounds which have enjoyed 
the greatest reputation, and the absence of which might here be 
regretted; I refer to the syrup of Cusinier and the tisane of Feltz : 

SYRUP OF CUSINIER. 

I£. Sarsapar. Jbi. 

Aq. Com. 5>xii. 

Macerate for twenty-four hours, and reduce to four pounds. Having 
decanted the liquor, subject ivhat remains to the same operation twice. Mix 
these three decoctions, and add : 

Flowers of borage, | ii. 

White Roses, f ii. 

Aniseed, § ii. 

Senna, f i. 

Boil until reduced one half ; add : 

Sugar, fti 

Honey, fi>i. 

Dose, half a glass three times in a day, with the sarsaparilla tisane. 

This is the syrup of Cusinier, of the first, second, and third boil- 
ing, that is after we add one, two, or three grains of the bi-chloride 
of mercury to each pint of the syrup, according as we wish to 






SYPHILITIC ERUPTIONS. 331 

increase, or more properly speaking, to realize its anti-syphilitic 
virtues. 

M. Baumes prescribes, morning and evening, with two or four 
tablespoonfuls of the syrup of Cusinier, half a tablespoonful, or a 
whole spoonful of Yan Swieten's liquor, the dose of which is gradu- 
ally increased. 

In the place of the deuto-chloride we may introduce into the 
syrup of Cusinier, the cyanuret of mercury, which is less easily 
decomposed. But M. Baumes observes that we must then atten- 
tively watch the administration of the syrup when this addition 
has been made, its action on the digestive organs being severe : 



^ . Sarsapar. | ii. 

Icthyocol. 3 iiss. 

Sulph. Ant. (washed,) § iii. 

Aq. R)iv. 

Evaporate to one pound. A glassful to be taken daily. The sulphuret 
of antimony is ordinarily washed in boiling water. 

M. Eayer, who employs this preparation, very frequently re- 
marks that we thus remove a large portion of the arsenic contained 
in the sulphuret of antimony, by which its efficacy is partly de- 
stroyed. But as the proportion of the arsenic contained in the 
tisane is sometimes too considerable when the antimony is not 
washed, M. Eayer often prescribes, in the place of the tisane of 
Feltz, the following : 



^ . Decoc. Sarsapar. § xvi. 
Arsen. Sod. gr. ~. 



CHAPTER II. 

ON SPECIAL CONSECUTIVE VENEREAL AFFECTIONS. 



SECTION I. 

SYPHILITIC ERUPTIONS. 



Syphilida. — Syphilides. — Syphiloderma. ■ — When the syphilitic 
virus has infected the system in a certain manner, various eruptions 
are produced upon the skin. They assume almost every element- 
ary form of cutaneous disease, but have certain peculiarities which 
reveal their nature. 



332 VIDAL ON VENEREAL DISEASES. 

So common and grave were the affections of the skin in what 
was called the epidemic of the fifteenth century, that they did not 
fail to attract the special attention of observers. From that epoch 
to a period nearer our own, every syphilitic eruption was con- 
founded under the name of pustules. In calling these eruptions 
syphilides, Alibert rendered a double service to science : he created 
a happy and precise denomination, and contributed to destroy the 
false idea to which the word pustule, used as a generic term, gives 
rise. But it is to Biett and his pupils that we are indebted for the 
proper application of Willan's method to the study of the syphil- 
ides, and for a classification based upon the elementary lesions of 
the skin. No one can deny the advances here made by this school ; 
but it is equally true that much yet remains to be learned in the 
study of these eruptions. 



I.—GENERAL CHARACTERS. 

I proceed, in the first place, to describe the general characters of 
the syphilitic eruptions ; I shall afterwards classify them, and study 
each variety according to the divisions established since the school 
of Biett. 

The syphilitic eruptions present a physiognomy that cannot be 
mistaken when once the attention has been fixed upon them. This 
physiognomy consists in the color, form, chronicity, and marks 
which they leave behind. 

Color. — The color of these eruptions, the ham-color of Fallopius, 
tne copper-color of Swediaur, has always arrested the attention of 
observers. It is still regarded as the most characteristic feature, 
that on which the differential diagnosis of these eruptions is based, 
that which distingushes them from simple eruptions or those of 
any other nature. And yet the value of this test has been dis- 
puted and even denied ! It is true, that after certain ulcers, cer- 
tain simple eczematous eruptions, especially on the legs, we ob- 
serve the skin to assume nearly the same tint ; sometimes, also, 
the spots of purpura, before they disappear, become of a faint red 
color ; but the slightest inquiry into the circumstances preceding 
the first stages of the disease will remove all doubts. Instead of a 
well-marked tint, there sometimes exists a shade difficult of detec- 
tion. Fallopius was the first to remark : non enim ruber, non alius, 
non pallidus. There are cases, says M. Cazenave, where the red- 
ness is but slight, the tint varying from this to a gray color. 
Again, the shade may depend upon the period of the disease as 
well as other circumstances : thus, at the moment of the erup- 
tion of roseola, of the papular form of the disease, the color is of a 
bright red, which becomes darker as the eruption becomes more 
distinct, as is represented in plate 5, fig. 1. Is this owing to the 
vascular congestion in the first period masking the alteration of 
the chromatogenous apparatus ? or is it rather owing to the fact 
that this apparatus is not yet modified ? There are cases in which 
we may distinguish the two colorations : thus, in certain tuber- 



SYPHILITIC ERUPTIONS. 333 

cular affections, by pressing with the finger and emptying the ves- 
sels, we may cause the redness to disappear ; but the copper color 
remains, because it depends upon a matter which is combined with 
the layer of the skin. In the last stages of certain lenticular 
squamous syphilitic eruptions, we observe the coppery red pass 
into an obscure grayish yellow, which is called the dirty coppery 
yellow. 

The quinine tubercles and pustules leave behind livid spots of a 
dark red color, like the ecchymosis of purpura. But even then, 
if we carefully examine the whole surface of the skin, we shall 
find places exhibiting the coppery -red color. Sometimes, instead 
of being effaced by the long standing of the disease, the redness 
continues and becomes more distinct. Thus, we occasionally find 
red spots long after the eruptions have disappeared. Cold appears 
to affect the color of certain of the syphilitic eruptions ; roseola is 
one of those which it renders more apparent. 

The persistence of the color of these eruptions, their chronicity, 
and the impossibility of causing them to disappear by pressure, 
seem to prove that the affection, in these cases, is seated between 
the epidermis and the dermis, in what is called the rete mucosum — 
in other words, in the chromotogenous apparatus, of which the 
secretion has been altered. 

I have already spoken of the varieties of tint which are peculiar 
to the period of eruption ; I should add, that on the base, to speak 
classically, there are individual shades, which depend upon modi- 
fications in the integument, and its vascularity. Thus, in certain 
subjects with a fine white skin, the redness is lively in roseola, and 
lichen, and especially as I have already stated at the commence- 
ment of these eruptions. Towards the termination, in males whose 
skin lacks transparency and vitality, the color is always duller ; 
often it is violet. In persons of a bilious temperament, the red- 
ness assumes a brownish shade. In those of a cachectic habit, the 
tint approaches that of a venous injection, being livid. I have 
now under my care a corpulent patient, of a very lymphatic and 
apathetic temperament ; he has had an indurated chancre, and this 
has been followed by livid spots upon the skin, which I should 
never have regarded as syphilitic, had I not seen the development 
of all of the phenomena. It is in such subjects that the cicatrices 
of the syphilitic eruptions which ulcerate, have a blueish appear- 
ance. In conclusion, the coppery tint is one of the best signs, for 
it seldom occurs in other than syphilitic affections ; it may of 
itself, in certain cases, establish the diagnosis, but it must then be 
very decided, so as not to be masked by any complication with 
other diseases. In every case we should observe all the features 
which complete the physiognomy of a syphilitic eruption. 

Form. — The most important symptom, next to the color, is the 
form of the eruption. It is generally curved, circumscribing por- 
tions of a circle, or entire circles, or roundish spots. This is ob- 
served not in isolated places only, and limited to small portions of 
the surface, but whole groups of vesicles, of tubercles and scales 
are thus surrounded. True, this feature is wanting in certain of 



334 VIDAL ON VENEREAL DISEASES. 

the eruptions, as in the papular form, and it is found in some 
cutaneous affections than the syphilitic, for simple herpes may 
assume the circular form. But there are eruptions which do not 
exhibit this character, except when they are of a specific, of a 
syphilitic nature : thus, the elements of the tubercular eruption 
grouped together, are surrounded by a circle more or less complete, 
more or less perfect. What is remarkable is, that we see, occa- 
sionally, the circle formed partly by one and partly by another 
organ : thus, in the horny syphilitic eruption, we sometimes ob- 
serve a segment of a circle on the palmer surface of the finger, 
whilst the other segment is inscribed upon the adjoining finger. 
I have under treatment a patient who is affected with herpes cir- 
cinnatus on the genital organs ; one-half of the circle exists on the 
root of the penis, the other upon the scrotum (plate 6, fig. 1). For 
a long time this singular disposition of syphilitic eruptions has 
attracted the attention of observers : thus the term corona veneris is 
a very old one. 

Phronicity. — A syphilitic eruption being essentially a chronic 
affection, we find that the sensibility of the parts is but little modi- 
fled ; thus, there is neither acute pain nor pruritus, even in those 
forms assumed by the eruptions which, in their simple state, are 
sometimes remarkable for their intolerable itching. Heat is a 
symptom which is also absent. However, even here, we must 
not be too absolute, and deny any changes of sensibility or of the 
temperature, in every stage of the eruption. Thus, of seventeen 
patients, M. Legendre remarked that thirteen suffered not the 
slightest pruritus, but three complained of it a little, while in the 
fourth, it was very severe. During the first stages of a tubercular 
eruption, it is not uncommon to hear patients say that they feel an 
itching sensation in the evening, when they begin to get warm in 
bed, and facts are not wanting to show that a true febrile excite- 
ment has preceded a syphilitic eruption. 

The chronic character of these affections is due, not only to the 
absence of alterations of the sensibility in the majority of cases, 
but to the slow pathological processes which are observed in cer- 
tain forms. Thus, in the pustular form, we sometimes observe a 
large indurated base, surmounted by a small suppurating point ; 
in the vesicular variety, we find the vesicle remaining unbroken, 
and preserving its transparency for four, five, or six days, sur- 
rounded by an areola, the redness of which soon fades. 

Ulcerations. — These are much more frequently observed as sec- 
ondary lesions of the syphilitic than after ordinary eruptions, for 
herpes zoster and ecthyma alone offer this peculiarity. The exca- 
vated ulcer of the syphilitic eruptions is generally of a regularly 
roundish form, with reddish, perpendicular edges, with a grayish 
and sometimes a bloody base. These characters are especially to 
be seen on the lower extremities. Occasionally the ulcer assumes 
an oval form ; sometimes its edges are irregular and scalloped ; 
then a group of small ulcers is confounded into one of larger 
dimensions, the edges of which involve a portion of the circum- 
ference of the constituent ulcers : in this manner it is enlarged by 



SYPHILITIC ERUPTIONS. 335 

the process of ulceration. There is another method, viz., mortifi- 
cation : thus, at some point of the circumference, the dead skin 
and the separation of the eschar produce a loss of substance which 
enlarges the ulceration. I shall return to this phenomenon in 
describing the serpiginous ulceration. Most generally the ulcer 
increases regularly in all directions, and is arrested only when it 
has attained a certain diameter : thus, M. Legendre remarks that 
he has never seen a cicatrix of an isolated ulcer present a diameter 
of more than a five-franc piece. The ulceration of a syphilitic 
eruption has a much more decided tendency to reparation than 
that which supervenes on other cutaneous affections. It remains 
but a short time stationary, and tends rapidly to heat, whilst non- 
syphilitic ulcerations of the extremities remain unchanged for two 
and even three years. But, most frequently, during the cicatriza- 
tion of a syphilitic ulcer at one point, another is progressing at 
another point ; or, if but one ulcer exist, whilst one portion of it 
is undergoing reparation, another is enlarging its dimensions : the 
ulcerations losing nothing in this contest with the reparative 
forces. Thus, taking the syphilitic ulcer altogether, we see that a 
very long time is required for its cure. 

I treated, in Ward 11, Bed 26, a barber, who was affected with 
both forms of the serpiginous ulceration to a truly incredible ex- 
tent, and in this case I obtained extraordinary success from dress- 
ings with the vigo cum mercurio. This patient had an indurated 
chancre on the penis, several superficial eruptions, ulcerations in 
the throat, and syphilitic engorgements of the testicles ; last of all, 
he had large ecthymatous pustules, which ulcerated to such an 
extent, that on the 15th December, 1851, the right inferior extrem- 
ity presented two enormous solutions of continuity, which nearly 
came in contact with each other ; one was situated on the external 
border of the right thigh, reaching from the knee towards the 
trochanter, being nineteen centimeters six and one-third inches in 
length, and three and one-third in breadth ; the other commenced 
immediately below the patella, occupied the external, anterior, and 
somewhat of the internal surface of the leg, extending towards the 
foot, and was five inches in length, and six and two-thirds in 
breadth. On the external surface of the knee, these two ulcers 
were not more than some two-fifths of a line distant from each 
other. Three smaller ulcers were scattered on both lower ex- 
tremities ; on the left calf of the leg, and the popliteal space, there 
were two, one of which was of the size of a five-franc piece, the 
other of double the size. The patient was in a very serious con- 
dition, being exhausted by the suppuration. Internal and exter- 
nal treatment had failed. I then applied the dressings with little 
bands of the vigo. They were made to overlap as in the dressing 
by occlusion ; they were renewed every three days, and at each 
dressing there was a decided improvement, so that in less than a 
month, reparation was complete. The patient regained his embon- 
point, and his general condition was very satisfactory. Sometimes 
under the influence of this treatment, the patient became affected 



336 YIDAL ON VENEREAL DISEASES. 

with, a mercurial ulceration on the alveolar border of the lower 
jaw, and there was the commencement of a salivation. 

This case is highly instructive. We here see a patient who had 
been subjected to various external and internal measures: 1st, 
simple cerate, opiated cerate, dressings of aromatic wice, repeated 
cauterization, emollients, solutions of iodine ; 2d, combinations of 
mercury and iodide of potassium ; simple mercury, iodide of po- 
tassium alone, the preparations of iron, cod-liver oil, all failed. I 
employed the dressing already mentioned, and this measure was 
crowned with speedy success. Was it owing to the physical, local 
action of the plaster, or was it the result both of the local and the 
general action? I have stated that the mouth became affected 
as during a mercurial treatment, and we know that the vigo con- 
tains mercury, and that it was applied to very large surfaces. In 
this case, then, a feeble subject, in the last stages of syphilis, was 
cured by the external application of the mercury ! 

Cicatrices. — The cicatrices left by syphilitic eruptions generally 
present the following characters ; they are circular, and more or 
less depressed ; when recent, they have a bronze color, and some- 
times their tissue is slightly prominent; beneath the epidermis, 
we see the superficial vessels broken ; at a later period these be- 
come effaced, and a kind of internal absorption seems to be estab- 
lished ; they lose their violet tints, become white and more de- 
pressed ; their surface, of a dull white color, is also tense or corru- 
gated, shining or swollen, and sometimes furrowed with hard and 
prominent bands. Under certain circumstances they are white 
from the first, but of a blueish white ; they are then surrounded 
by a coppery areola which tends constantly to diminish, and the 
color of which is gradually lost in the surrounding skin. Syphil- 
itic cicatrices may present bands similar to those following exten- 
sive burns ; they sometimes degenerate and become covered with 
a kind of keloides. This phenomenon has been noticed particu- 
larly to occur on the cicatrices of certain cases of rupia, and of the 
serpiginous tubercular variety. When I come to treat of this 
form, I shall relate a very remarkable example of this cicatricial 
degeneration. 

IL— VARIETIES 

Having described the general character of the syphilitic erup- 
tions, I proceed, in the next place, to study them in particular. 
Following the example of M. Cazenave, I shall establish seven 
varieties : 



1. 


Exanthernatous. 


(Fig. l,pl.5.) 


•2. 


Papular. 


(Fig. 2, pi. 5.) 


3. 


Squamous. 


(Fig. 3, pi. 5.) 


4. 


Vesicular. 


(Fig. 1, pi. 6.) 


5. 


Bullous. 


(Fig. 4, pi. 5, et fig. 2, pi. 6.) 


6. 


Pustular. 


(Fig. 3, pi. 6.) 
(Fig. 5, pi. 6.) 


7. 


Tubercular. 



PI 5 



B| 



Efi.l 



,.: 



Ed. 2 



• 



*w- 







i 



Fid. 3 





Fin 



Efi.l. c>^wfew^z< Eg. 2 ^<z/i///s? Fig .3 . <-^hrtMzJ€J '. Fifi.4. r^e s??AA/^<t/J 



PI. 6 





Fid 2 
5 



s*> 



I 



IP 



•**» 






Fid. 3 




Fig. 



^- : , 









SYPHILITIC ERUPTIONS. 337 

At the head of each variety I shall offer a few remarks on the 
corresponding eruption regarded in its simple states, and this for 
the benefit of the young practitioner who may not remember facts 
which are indispensable in the study of these eruptions. 

EXANTHEMATOUS SYPHILITIC ERUPTIONS. 

According to Willan, the exanthemata are characterized by 
red spots of different forms, and scattered irregularly over the 
the surface of the body, the skin retaining its natural color in 
interspaces, and the eruption terminating in the exfoliation of the 
epidermis. This is the most common form of the syphilitic erup- 
tions. 

Roseola. — The syphilitic eruption which naturally comes under 
this category is the roseola, which strongly, resembles, both by the 
disposition of its spots, and sometimes even by its tint, common 
roseola, rubeola. But the syphilitic eruption sooner or later as- 
sumes the coppery tint (pi. 5, fig. 1), and towards its termination, 
a grayish shade. The color slowly disappears under the pressure 
of the finger, and generally it does not perfectly disappear. 
Eoseola is observed principally on the anterior part of the base of 
the chest, the neck, face, and extremities, particularly the supe- 
rior. The eruption has no particular, form ; the patches are ir- 
regular, sometimes circular ; at first view they appear somewhat 
elevated, but this error is soon, corrected by passing the finger 
over them. They gradually increase in numbers, sometimes rap- 
idly, so that the whole eruption is established in twenty -four hours. 
The color of the roseola may vary during the progresss of the 
disease, either from known or unknown influences. Thus the 
spots become more distinct under the influence of cold after emerg- 
ing from a bath, and mental emotions may cause the reappearance 
of an eruption which for some time had disappeared. This phe- 
nomenon occurs especially in cases of chronic roseola. Sometimes 
in the place of a coppery -red color it is a yellowish red, constituting 
the salmon-colored skin. (J. S. Petit. Hennen.) Finally, a period 
arrives when there is a very slight exfoliation of the epidermis, the 
tint becomes grayish, and the portions of the skin which have 
been colored now appear as though they were only dirty. 

Most generally roseola is not preceded by any febrile excite- 
ment, and the patient is sometimes astonished to find his body 
red, a fact which serves to distinguish this syphilitic eruption from 
the corresponding simple exanthemata, and from rubeola. But in 
some cases we observe febrile reaction from acute affections of the 
skin ; these cases are rare. What is much more common, is to 
notice a slight indisposition for two or three clays, lassitude, 
cephalalgia, and wandering pains in the limbs, the pulse not 
being sensibly affected. 

Eoseola occasionally assumes a character somewhat acute, and 
we then observe febrile symptoms before, and even after, the ap- 
pearance of the eruption ; the patient then also experiences a kind 
of pruritus, which, however, is very rare, for roseola is accompa- 

22 



338 VIDAL ON VENEREAL DISEASES. 

nied neither by heat nor itching. „ These characters belong espe- 
cially to the exanthematous eruption, which follows soon after 
chancre, the starting point of the disease, and with which the 
eruption may co-exist. The duration of this form of roseola varies 
from three to four weeks. Those who have spoken of two or 
three days probably do not know that the eruption, in certain 
cases of roseola, becomes so pale as to lead to the suspicion that it 
has disappeared, though it soon becomes again distinct. 

Chronic roseola is not attended with' febrile excitement, either 
before or after the eruption. It is sometimes developed by men- 
tal excitement, or any excess. It lasts for several months ; and 
occasionally for a longer period. I was astonished to read the 
following in the work of M. Cazenave: " Eoseola is one of the 
forms of syphilitic eruptions least frequently observed." Accord- 
ing to my experience, on the contrary, it is one of the most com- 
mon. This difference in opinion probably results from the differ- 
ence in our fields of observation. M. Cazenave is attached to the 
hospital St. Louts, where patients enter long after they have be- 
come infected with syphilis, and at a time when roseola has dis- 
appeared, and no account is taken of it among the antecedents of 
the case. At the Hopital du Midi, patients are admitted at an 
earlier period, so as generally to be treated for the first stages of 
syphilis. Then, when they remain for some time, the first ap- 
pearance of the syphilitic eruption is observed. Now roseola 
occurs the first after the primitive accidents, at least in the major- 
ity of cases. It is therefore possible, that more cases of the kind 
are seen at the Hopital du Midi than at the St. Louis. 

M. Cazenave classes under the exanthematous syphilitic erup- 
tion, a papular erythema, which, in my opinion, and that of other 
writers on sj^philis, has all the characters of the eruption observed 
after the administration of copaiba, and which quickly disappears 
on the discontinuance of this remedy. This is certainly improper. 

Eoseola is often blended with some other eruption ; it frequently 
precedes the papular form, which seems the second stage of a 
consecutive affection of the skin. A very common accompaniment 
is an affection of certain mucous membranes, as of the throat, anus, 
vagina, prepuce, and glans. 

. SYPHILITIC PAPULAR ERUPTION. 

At the close of the first chapter, I have spoken of papules which 
appear on the mucous membranes and adjacent portions of the 
skin. These papules are generally more or less large, confluent, 
and moist ; they are also called mucous tubercles. Those under 
consideration are smaller and harder, they are distinct and dry, 
secreting no purulent matter ; they terminate by desquamation or 
simple resolution. Fig. 2, plate 5, gives an exact representation 
of a syphilitic papular eruption. We there see elevations, some 
of which are larger than a pin's head, others the size of a lentil ; 
their summit is covered with a little crust ; all are surrounded by 
a copper-colored circle; they are scattered irregularly, some in 



SYPHILITIC ERUPTIONS. 339 

groups, others are isolated. They were particularly numerous on 
the anterior surface of the base of the chest, and on the abdomen. 
The patient was fifty-four years of age ; and occupied Bed No. 4, 
Tv~ard 12, of my service. It was preceded by an indurated chan- 
cre on the prepuce, which appeared on the 20th January, 1852, 
whilst the eruption first showed itself on the 19th of the following 
March. Papules may appear on all points of the skin, but they 
are more common on the back, shoulders, and nape of the neck. 
After an uncertain duration, they terminate, in the majority of 
cases, by resolution ; they leave behind only a slight tawny stain 
at first, which gradually assumes the color of the skin, and finally 
completely disappears. Sometimes, and especially when large, 
they are covered, as it were accidentally, with a very light scale, 
which adheres but slightly. M. Cazenave has several times seen 
not only spots, but little, genuine cicatrices follow these papular 
eruptions at certain points, although these papules had not ulcer- 
ated, an occurrence which is, at least, very rare in the papular 
form of syphilitic eruptions. 

Syphilitic Lichen. — This manifests itself in the form of very small 
pimples, which are often innumerable; sometimes they may be 
called confluent, and then they present a kind of brilliancy which, 
added to their coppery color, constitutes a very remarkable tint. 
According to Carmichael, this eruption often accompanies a blen- 
norrhagia ; it also appears almost always like certain acute exan- 
themata, that is nearly simultaneously, having been preceded by 
cephalalgia, lassitude, anorexia, and occasionally even with a little 
fever. Syphilitic lichen is ordinarily of short duration, that is, it 
may disappear in the course of a fortnight, by resolution. It may 
fade, and sometimes there is a slight, imperceptible desquamation, 
leaving only spots, which do not long continue. These, I repeat, 
are the ordinary characters, and this the ordinary progress of a 
syphilitic lichen ; it may, however, pass under the same form into 
a chronic state. 

Syphilitic broad papular Eruption. — The papules in these cases 
are preceded by small, yellowish, and very regular circular spots ; 
they are always isolated, and distinct, and generally scattered over 
very extensive surfaces, which are successively invaded ; some- 
times we observe them of a firm consistence, very prominent, and 
of a decidedly copper color ; at another point, we find little eleva- 
tions already faded, less prominent, of softer consistence, and of a 
paler tint ; on one side are yellowish spots with a rosy tint, which 
are in process of being converted into papules ; on the other, they 
are of a grayish shade, more depressed than the latter, and the 
marks left by the papules which have disappeared. They are 
separated by intervals, at which the skin is of a peculiar earthy 
color, giving to the whole a very characteristic aspect. 

These papules occur particularly on the extremities, shoulders, 
nape of the neck, very frequently on the forehead, and sometimes 
even on the hairy scalp. Occasionally the patient suffers pruritus, 
but it is always very moderate. Sometimes the papules are covered 
with pellicles, which never exist simultaneously at every point of 



340 VIDAL ON" VENEREAL DISEASES. 

the eruption. The pimples often remain intact. This form con- 
stantly pursues a chronic course ; it may continue stationary for 
several months, until the papules disappear by a slow and im- 
perceptible resolution. They may be complicated with other ve- 
nereal eruptions, or other consecutive accidents, such as secondary 
ulcerations of the throat, exostosis, or what is still more common, 
iritis. 

SYPHILITIC SQUAMOUS ERUPTIONS. 

The squamous affections of the skin are characterized by the 
formation of the gayish white, dry scale, which is more or less 
thick and adherent. In the syphilitic eruption, these scales are 
formed in a more or less, elevated surface, which is of a dark red, 
or coppery color. 

Syphilitic Psoriasis. — These patches occur on one or several 
regions of the cutaneous surface (pi. 5, fig. 3) ; there may be inter- 
spaces, or they may sometimes exist in close contact. Their 
breadth varies from that of a lentil to that of a franc piece, or it 
may even exceed this measure ; they are more or less irregularly 
circular, and are elevated beyond the adjoining parts. They are 
covered with shining scales; when they become detached, the 
surface remains smooth and of a dark color. According to Biett, 
when this variety resembles psoriasis guttata, when the scales fall 
off, the patch, is surrounded by an adherent white narrow border. 
This is of frequent occurrence, but not sufficiently constant as to 
establish a pathognomonic sign. 

Syphilitic Lepra. — It is probable that this is the affection chiefly 
described under the name of lepra nigricans, and which by M. 
Ricorcl is called syphilitic annular eruption. The patches are per- 
fectly circular, from two lines to half an inch in diameter, and 
generally of a deep brown or violet color, or even of a blackish 
tinge in their centre. Their edges form a circle more or less per- 
fect, and are raised above the level of the surrounding parts. This 
circle is sometimes enlarged by the healing of the portions corre- 
sponding to the centre, and the development of these at the cir- 
cumference. The color is here less dark than at the centre of the 
patches ; but if the affection continues without an increase of its 
dimensions, the skin resumes its normal color in the centre, and 
the circles alone remain colored for a longer or a shorter time. In 
the majority of cases, these circles are formed by a tumefaction of 
the tissues, but there are those in which the scales are alone ob- 
served ; then, in becoming detached, they leave beneath a circle 
which does not project, but which is simply a reddish narrow 
border. In other instances these circles are formed by more or 
less perfectly-developed papules in contact with each other, and 
whose summits are covered with crusts of greater or less thick- 
ness ; the circle has then the appearance of honey comb. These 
circles meeting at different points, assume the form of the figure 8 : 
when they are imperfect they are like the figure 3, or the letter S. 
This form is verv common. 



. 



SYPHILITIC ERUPTIONS. 341 

"When syphilitic psoriasis and lepra affect the palms of the hands 
and the soles of the feet, which is of very frequent occurrence, the 
scales are thicker and harder, resembling horn (syphilide cornee), a 
fact which is explained by the nature of the epidermis in these 
regions. If, on the contrary, the skin be moist and contiguous to 
mucous membranes, as in the vicinity of the arms, the vulva, and 
the genito-crural fold, the scales are soft and pultaceous. 

SYPHILITIC VESICULAR ERUPTION. 

By the term vesicle, in cutaneous pathology, we understand an 
elevation of the epidermis, by a serous or a sero-purulent humor. 
"When the latter is sufficiently abundant to produce a small tumor, 
it is called a bulla. Thus, we speak of the vesicle of eczema, and 
the bulla of pemphigus. 

The vesicular form of eruption was, until recently, considered 
exceedingly rare, because it was not often observed, or to speak 
more properly, we did not know how to observe it. It assumes 
all the forms of the simple affections of the skin which are charac- 
terized by vesicles. Thus, we have an eczema, a syphilitic herpes, 
and a varicelloid syphilitic eruption. 

The vesicular eruption occurs on almost every portion of the 
skin, but particularly on the neck, chest, and extremities, especi- 
ally the superior extremities : it is seldom seen on the face, where 
venereal eruptions so often occur. It sometimes appears shortly 
after the primary accidents have disappeared; it happens even 
that it has begun before the latter have completely subsided. "We 
know how rapidly the vesicles of herpes become discharged. The 
vesicular syphilitic are often complicated with other forms of syph- 
ilitic eruptions and with angina ; and there are also pains in the 
extremities. 

Syphilitic Eczema. — This variety appears under the form of small 
transparent vesicles, like those of simple eczema, but a little more 
elevated ; they form irregular groups scattered in various places, 
and are surrounded by a coppery circle. At other times the erup- 
tion consists of patches of characteristic redness, not very bright, 
and covered with very Jarge prominent vesicles of more than or- 
dinary hardness, and which remain a long time unbroken and 
stationary ; ordinarily the fluid of the vesicles preserves its trans- 
parency, or becomes but slightly turbid ; they become faded, the 
areola or coppery patch is more tawny and gray, the fluid is ab- 
sorbed, the epidermis subside, and there remains but a slight ex- 
foliation, which contrasts ordinarly by the brightness of its narrow 
border with the peculiar tint of the skin first occupied by the 
vesicle. This is the progress of the most common form of syphi- 
litic eczema. 

M. Cazenave has described an impetiginous eczema. It consists 
of groups of vesicles which cover patches of very bright redness 
and of variable extent. These vesicles, at first transparent, are 
turbid, the fluid is sero-purulent ; they become covered with crusts. 
There are successive eruptions which follow a similar course; 



34:2 VIDAL ON VENEREAL DISEASES. 

sometimes the vesicles rest on copper-colored patches ; the scabs, 
of much greater thickness than those of simple impetiginous 
eczema, have the character of other syphilitic scabs ; they are 
black, conical, furrowed, thick, and adherent. M. Cazenave once 
observed the crust covering the ulcerations of a perpendicular 
form, and of such depth, that they left behind so many depressed 
cicatrices. " This disease," he remarks, " had lasted for several 
months, always retaining the same unmistakable characters, and 
nearly always presenting at the same time each of the lesions I 
have mentioned. A number of depressed cicatrices were left, 
which covered the whole anterior surface of the abdomen."* 

M. Rayer observed a remarkable case of syphilitic eczema, and 
the following is an analysis of his report : " The eruption was 
seated on the fore-arm. There were small irregular groups nearly 
the size of a dime (American) piece, consisting of small reddish 
elevations, not pruriginous, and of the size of a pin's head ; they 
contained a turbid or opaque matter. The vesicles were more 
prominent, globular, and as voluminous, than those of simple 
eczema. They were smaller, less transparent, and disposed in 
more irregular groups than those of herpes. Their reddish and 
slightly livid hue served to distinguish them from the pustules of 
impetigo. At other points were to be found little circles analo- 
gous in form and size to those of rubeola. In some of these 
groups several sunken vesicles were replaced by a slight exfolia- 
tion of the epidermis, distinctly presenting at several points a 
narrow border which indicated the size of the vesicles. Where- 
ever the exfoliation had just commenced, there were spots having 
completely the hues of ordinary syphilitic maculas. Finally, this 
eruption differed from psydracious pustules in this, that the eleva- 
tions in the latter were more voluminous and acuminated, and are 
commonly followed by crusts and sometimes by cicatrices.f 

Syphilitic Herpes. — Here we have vesicles arranged in circles, 
as in herpes circinnatus. The breadth of these circles varies 
from that of a fifty-centime piece to that of two francs. ' Syphi- 
litic herpes, besides the antecedents and other concomitant lesions 
of the same nature, is characterized by a coppery tint of the por- 
tion of the skin occupied by the circles, 'a tint which at a later 
period becomes of a grayish hue. These circles are not very 
numerous, and are widely separated, since the eruption may simul- 
taneously occupy even one or two regions, and be represented 
by one circle only. As I have already stated, I have seen a case 
where the herpetic circle occupied partly the root of the penis, 
and partly the scrotum. It is not unusual to observe this in the 
other syphilitic eruptions. M. Cazenave has described a syphilitic 
herpes which corresponds to a variety of simple herpes. The 
discs are most frequently very small and numerous. They occur 
principally on the chest and on the extremities. On their first 
appearance they may be covered by a pea, whilst at a later period 

* Traite des Syphilides, p. 253 et suiv. 

f Rayer, Maladies de la peau, t. ii., p. 384. 



SYPHILITIC ERUPTIONS. 343 

the circle may so enlarge as to equal that of the preceding 
variety. The vesicles are also very small, and become rapidly 
desiccated, a circumstance which sometimes leads to their being 
undetected. These patches may be mitaken for squamous discs, 
if with a glass or a practiced eye we do not discover numerous 
points surrounded by epidermic debris, and disposed in circles. 
To these characters may be added an inflammation of the area, 
which seems elevated by a liquid which is speedily absorbed, and 
a scale sometimes sufficiently large to fill the circle. According 
to M. Cazenave, this is the most common form of the syphilitic 
vesicular eruption. If it had not been described, it is because it 
has at times been confounded with eczema and pityriasis. As 
the discs are here very numerous and scattered over large sur- 
faces, the syphilitic tint is very decided. 

Syphilitic Varicella. — The vesicles here resemble the pimples of 
varicella. This is one of the rarest forms of the syphilitic erup- 
tions. The vesicles appear at one point, rapidly discharge, desic- 
cate, and reappear at other points. Sometimes there is a well-marked 
coppery red circle, sometimes a very narrow border, and some- 
times an entire absence of redness around the vesicle. The more 
I reflect, the more I am convinced that it was not this form of 
syphilitic eruption which occurred on the first patient on whom 
A. first inoculated the secondary accidents. This case I shall soon 
relate ; I called it syphilitic ecthyma in my report to the Societe de 
Chirurgie. But it will be remarked, that in my description of the 
characters of the eruption, I have observed that the principles re- 
sembled those of varicella. We know, moreover, that by some 
writers varicella .has been ranked among the pustules. There was 
in my wards a patient, who was attacked by variola (for it is 
not uncommon to find variola where we find syphilitis). Soon 
other patients became affected with analogous eruptions. Two 
patients who had had chancres were seized with certain general 
symptoms analogous to those which are ordinarily observed in 
eruptive fevers. Then pimples appear strongly resembling those 
of varicella. They were smaller, and surrounded by a reddish- 
brown narrow border. One of these patients would leave the hos- 
pital during the first stage of the eruption, and I lost sight of him. 
I was able to watch the other ; the vesicles remained for a long- 
time, much longer than those in ordinary varicella, and afterwards 
an ecthyma with large pustules followed, particularly on the legs. 
The syphilitic varicella may be inoculated, as proved by the fol- 
lowing observation : 

set. 26, of a lymphatic temperament, had several years since 

a chancre, which, when healed, left a little induration. Two months 
after the chancre had disappeared vegetations appeared on the 
glans ; these were excised and cauterized. No other consecutive 
accident supervened; the patient pursued no general treatment. 
Five years ago he contracted a blennorrhagia which was compli- 
cated with orchitis, and which required five months for its cure. 
About five months since he had another chancre which rapidly 
cicatrized without leaving any induration. Four or five days after 



344 VIDAL ON VEXEREAL DISEASES. 

tlie cicatrization of the chancre buboes appeared in the groins. 
The patient then entered the hospital of Toulon, where a mercurial 
treatment was administered, but he left the hospital at the end of 
twelve days, and discontinued the treatment. The tumors in the 
groins continued in an indolent state. About twenty days after 
he left the hospital he discovered an enlargement of some of the 
cervical glands ; six weeks later very large pustules, full of pus, 
appeared on both arms and thighs. The patient entered the Hopi- 
tal du Midi on the 22d October, 1849. He was immediately placed 
under the influence of mercury. He took pills of corrosive sub- 
limate for six days, when the pus from the pustules was inoculated. 
These pustules resembled the large pustules of varicella. The pus 
was taken from two different pustules on the left wrist. These 
pustules were intact. Two punctures were made on the internal 
surface of the thighs, one on each side. Two pustules, perfectly 
resembling those which had furnished the pus, were speedily de- 
veloped, and four days after the inoculation pus was taken from 
the pustules thus produced, and inoculated on the internal and 
superior surface of the thigh. Two pustules similar to the others 
followed this second inoculation ; all of the pustules thus produced 
corresponded perfectly with those which were spontaneously de- 
veloped. The patient took one hundred and eighteen pills. For 
eight days past he has taken fifteen grains daily of the iodide of 
potassium ; but a single pustule remains over the annular ligament 
of the left hand, and a slight engorgement in the left groins. ^ He 
asked for his discharge fifty-six days after his admission. 

I would add, that I have never seen pustules so rapidly de- 
veloped as were those which followed the first inoculation. It will 
here be remarked that seven years had elapsed since he was affected 
with the indurated chancre on the penis, and that the other symp- 
toms which had been manifested on that organ had long since dis- 
appeared. In conclusion, no primitive accident existed when the 
inoculation was performed. No doubt can therefore be entertained 
in regard to the inoculation of certain secondary accidents, and 
shortly afterwards I undertook some experiments, all the details 
of which will be found in the paragraph on the syphilitic pustular 
eruptions. It will then be seen that a secondary accident was 
inoculated from one man to another, and from the latter to a 
sound man. 

SYPHILITIC BULLAE. 

The elevation of the epidermis is here more considerable than 
in the vesicular variety. These tumors are called bullce, they are 
regularly circular, and vary in size from a pea to a goose egg. I 
shall describe both forms, pemphigus, and rupia. 

Syphilitic Pemphigus. — This is not described by every writer on 
syphilis. It must be very rare in the adult, for I do not remember 
having seen more than two patients at the Hopital du Midi in which 
this eruption could be traced to syphilis, and these two had had 
chancres and roseola. Having made no note of these cases, I can 



SYPHILITIC ERUPTIONS. 345 

speak of them only from recollection, which is too imperfect to 
render them of value. But there is at present, in the paying 
department of the hospital, a patient who presents three bullae or 
eruptions, in the form of pemphigus. The following are the par- 
ticulars of this case : 

T. (Claude,) set. 24, a cooper by trade, temperament sanguine, con- 
stitution good, admitted into room No. 5, on 19th September, 1851. 

Aug., 1850. Two chancres, of from twelve to fifteen days' stand- 
ing, were cauterized on the fourth day with nitrate of silver. In 
the month of August, 1851, a bubo in the left groin was opened 
by a chemist with caustic potash. There existed also an excoria- 
tion at the margin of the anus, which the patient attributed to 
habitual constipation. Simultaneously with the bubo, there were 
crusts of impetigo on the scalp, ears, and whiskers. Eheumatic 
pains chiefly in the lower extremities. Throat sound. 

At the moment of admission, there were crusts of impetigo on 
the head and eyebrows ; a scar in the left inguinal region, the 
result of the potash ; excoriations in one of the anal folds. The 
patient states that he is subject to constipation, and to a hemor- 
rhoidal flux, which has many times been followed by ulcerations, 
resembling that with which he was actually affected. The rheu- 
matic pains are not increased by the warmth of the bed. On the 
left side of the thorax, about on a level with the ninth rib, there is 
a recent cicatrix, of an oval form, and of a coppery -red color. 
(Plate 5, fig. 4, last spot.) 

Monday, Sept. 2 2d. On the left hand, on the dorsal surface of 
the fifth metacarpal bone, the epidermis is slightly elevated by an 
opaline serum. No pains. 

24th. A bubo of pemphigus has appears ; it has the breadth of 
a half-dime piece ; it is filled with a sero-purulent fluid, and is 
surrounded by a red areola. (Plate 5, fig. 4.) 

25th. The bulla has burst ; in its place is seen a coppery -reddish 
spot, which is dry, and a little elevated ; in its centre there is a 
small whitish point. (Plate 5, fig. 4.) 

26th. During the night, the bulla, which had formed again, 
again burst ; the red spot on which it was situated is distinctly 
circumscribed, hard, and not painful ; its coppery hue is more dis- 
tinctly marked. The patient would leave the hospital, and he was 
not again seen. 

I would here remark that this patient was young, robust, ple- 
thoric, and strong. 

According to the researches of Professor P. Dubois, syphilitic 
pemphigus has been especially observed among infants. Krauss 
studied this disease as it is met with in children, but he did not 
regard it as syphilitic. M. Dubois asserts that it may assume this 
character, and M. Cazenave, who has seen many children at the 
professor's clinique, is of the same opinion. M. Depaul has most 
commonly observed foci of engorgement in the lungs. In a me- 
moir which was read before the Academy of Medicine, this honor- 
able confrere maintained that this pulmonary lesion was related to 
pemphigus; in other words, that these engorgements were like 



346 YIDAL ON VENEREAL DISEASES. 

those of tlie skin of a syphilitic nature. M. P. Dubois defends the 
opinions of M. Depaul. M. Cazeaux is opposed both to M. Depaul 
and M. Dubois. According to M. Cazeaux, there is no proof of 
the syphilitic nature of pemphigus and pulmonary engorgements, 
in the double lesion which is found in infants. As to syphilitic 
pemphigus, it is but little known, having never been positively 
seen in the adult ; in the infant it may depend upon a state of de- 
bility. As to the engorged foci found in the pulmonary paren- 
chyma, they are also met with in the foetus, which cannot be sus- 
pected of being affected with syphilis. Thus, according to M. 
Cazeaux, the previous existence of syphilis in the parents would 
be no positive proof of the syphilitic nature of pemphigus and of 
the pulmonary lesions in the child. To establish this, it must 
have been observed at other periods of life, and the pulmonary 
lesions must have special characters, characters which differ from 
those where the lesions are developed under other influences, as, 
for example, cold. M. Dubois replies, that children born with 
pemphigus, or in whom it appears shortly after birth, have the 
aspect of old people, as is always the case in congenital syphilis ; 
nearly all of them die, and, in the majority of cases, we find proofs 
of previous syphilitic infection on the part of one or both parents. 
As to pemphigus, it is indeed rare, still it has been observed. An 
excellent example is represented in the Iconographie of M. Eicord, 
and I have mentioned another. 

More recently, Professor Dubois has reported to the Academy 
of Medicine the case of a woman completely infected with syphilis, 
who gave birth to a child affected with pemphigus ; it died, and 
at the autopsy engorgements were found in the lungs, and portions 
infiltrated with blood. I repeat, syphilitic pemphigus has been 
seen in the adult. It must, however, be confessed, that the ques- 
tion is not yet absolutely settled. But a practical question con- 
stantly arises, to which it were well a solution might be given. 
When parents have given birth to children who die with pemphi- 
gus, should the parents be subjected to an anti-syphilitic treat- 
ment ? Should one of them exhibit marks of syphilis, there can 
be no question as to the course to be pursued ; the person affected 
should submit to treatment. But, must the same course be pur- 
sued when both are free from all symptoms of the disease ? If the 
lesions in the child are really of a syphilitic character, it is suffi- 
cient evidence that the parents should be subjected to treatment. 
Thus, we find that the question is constantly recurring. Now, as 
it cannot yet be decided, in a practical point of view, we should 
obey the dictates of common sense. It may then be asked, is the 
treatment to which the parents are required to submit, to prevent 
the infection of the child in utero, attended with danger or serious 
inconveniences. Now, it is established that when mercury and 
iodine are prudently administered, they give rise to no accidents, 
or but to slight inconveniences. The anti-syphilitic treatment then 
should be cautiously employed, and adapted to the circumstances 
of the parents. I shall return to these questions when we come 
to treat of infantile syphilis. 



SYPHILITIC ERUPTIONS. 347 

Syphilitic Rupia. — This is characterized by large bullae, which 
are but little distended, perfectly round, and surrounded by a cop- 
per-colored areola. These bullae contain a darkish-colored humor, 
which speedily dries, leaving a blackish crust, which is thicker 
at the centre than the circumference. A violet-colored circle sur- 
rounds these conical crusts, which ulcerates, and always exceeds 
the extent of the bulla that preceded it. Beneath these crusts 
are perpendicular ulcerations, which are sometimes of considerable 
depth. 

The bullae of rupia are observed on all parts of the body ; they 
vary in number and dimensions ; they are generally few in num- 
ber, and scattered irregularly over different parts. There may be 
six or eight, and sometimes from twelve to twenty in number. 
The smallest rapidly pursue their course, whilst the larger are 
more protracted in their progress. In very rare cases, they are 
widely and in great numbers scattered over the surface of the 
body ; they are all of nearly equal volume, and resemble ecthy- 
ma, from which, however, they differ in their extent, the conical 
form of the crusts, and their elementary lesion, although, as in the 
circumstances there is no great difference between the pustule of 
ecthyma and the bulla of rupia, the latter being more extensive 
and superficial, and does not completely cover the diseased surface 
like the pustule of ecthyma. (Cazenave.) Syphilitic rupia may 
censist of one or two bullae only, situated more particularly on the 
extremities ; they are then of considerable dimensions, which is 
increased by the progressive ulceration at the base of the crust. 
Cicatrization may take place at certain points, and especially at 
the centre, whilst at other points the ulcer is covered with crusts, 
. principally at the circumference, where they seem to be main- 
tained by the succession of several isolated bullae, and when the 
ulcer assumes a phagedenic form. 

The gravity of syphilitic rupia is in proportion to the debility 
of the subject. It is rarely complicated with other symptoms. 
Its progress is always slow. Its cicatrices are indelible, retaining 
the circular form of the ulceration, and preserving for a long time 
the characteristic impress of syphilis. These cicatrices sometimes 
degenerate, and give rise to what Alibert denominates Keloides. 
Eeparation is manifested by a drying of the crusts, and fading of 
the circle, at which point a lamellar exfoliation occurs. Plate 6, 
fig. 2, represents a rupia on the superior extremity ; reparation 
has commenced. The crust is divided into several fragments. 
•We see the lamellar exfoliation. Pressure with the finger on the 
summit of the crusts produces no discharge of serum. On per- 
cussion, they yield a dry and clear sound. The crust falls off in 
fragments, permitting us to observe successively more consider- 
able portions of the cicatrix. 

SYPHILITIC PUSTULAE EKUPTIOX. 

These consist in small tumors formed by the accumulation of a 
purulent humor on the surface of the dermis by which the epider- 



348 VIDAL OjS" yexereal diseases. 

mis is elevated. After M. Cazenave, I shall describe a syphilitic 
lentigo, an impetigo, and an ecthyma. This is an important section, 
as we have here to consider a form of the secondary accidents, at- 
tended -with the formation of pus, in other words, with the circum- 
stances most favorable to propagation by inoculation. 

Syphilitic Lentigo. — According to M. Cazenave, this is the most 
common of the pustular eruptions : it is the most frequently mis- 
taken. The pimples are distinct, isolated, of the breadth of a small 
lentil, slightly prominent, of a very decided characteristic color, 
imperfectly suppurating, and terminating by a small cicatrix, much 
smaller than the pustule that has preceded it. It may occur on all 
parts of the body ; it is disposed irregularly, and differs somewhat 
in form according to its situation. On the face, chest, and back, 
it strongly resembles acne ; but its pustules are larger, more circu- 
lar, and prominent ; in certain parts of their extent, they suppu- 
rate, when they become covered with a crust, which is sometimes 
very thick, and which, when it falls, leaves a very broad, depressed 
cicatrix, that remains for a long time like the base of a tubercle. 
On the extremities, we find the pustules flattened, particularly at 
their base, which is broader, and not so perfectly circular as in the 
preceding case. These pustules, of a coppery hue, and a bright 
red color at the commencement, appear in the form of a small 
lentil seed. The spot which first appears is sometimes painful ; 
and evidently presents a slight elevation ; the central point be- 
comes prominent ; and we soon perceive, completely on its sum- 
mit, a very small collection of pus, which disappears after one or 
two days, either by absorption, which is most rare, or by a rupture 
of the summit, or by the formation of a slightly-adherent crust in 
the place of the coagulated humor, which crust soon becomes de- 
tached. " Whatever may be the cause, the pimple has assumed 
another aspect ; it now appears as a small, copper-colored papule, 
which somewhat resists the pressure of the finger, presenting at its 
summit a small depressed cicatrix, which is sometimes completely 
perforated in the centre, and which, particularly for some time, is 
surrounded by epidermic debris. As the eruption advances, it 
loses more and more its pustular character ; at first view, it is 
called a papule, though it has several decided features, which 
should prevent such a mistake. This eruption, moreover, is for a 
long time kept up by the appearance of new pustules, so that it is 
easy, in the majority of cases, to observe the different stages al- 
ready mentioned. This is the variety of syphilitic pustules which 
is the most commonly mistaken ; a fact which explains why, ii0 
the view of certain pathologists, the syphilitic papule is regarded, 
though certainly without foundation, as one of the most frequent 
forms of the disease." (Cazenave, p. 286.) I will not deny the 
errors in diagnosis committed before the investigations of M. Caze- 
nave ; but, even after having profited by his researches, I must 
still regard the papule as one of the most common forms of the 
syphilitic eruption. 

Syphilitic lentigo always pursues a chronic progress ; its pus- 
tules, always distinct, never ulcerate ; they terminate by an indu- 



SYPHILITIC ERUPTIONS. 349 

ration of the base, which finally subsides, leaving a completely in- 
delible central cicatrix. 

Syphilitic Impetigo. — This assumes two forms : one very simple, 
corresponding to the vesicular variety, in the form of varicella 
(lesion nearly vesicular) ; it is the impetigo non confluent (pi. 6, fig. 
3, the first pustules). Here the pustules, somewhat voluminous, 
remain isolated, or if confluent, it is the result of accident, and 
only two or three are involved. A bright coppery-colored spot 
at first appears, followed by an elevation of the epidermis which 
completely covers this spot. The base of the pustules is not in- 
durated, and they form so many small tumors filled with a puru- 
lent fluid ; they are generally in close proximity, without, how- 
ever, coming into actual contact, and are surrounded by a reddish 
circle. It is rather in the skin by which they are separated, than 
in the distinct areola of each, that we observe in the commence- 
ment that peculiar tint which becomes more and more decided, as 
the eruption advances. This tint passes into the state of a macula 
at the points first occupied by the pustules. 

The non-confluent impetigo is preceded by general symptoms 
of indispositions, languor, lassitude, &c. The eruption may ap- 
pear at once over a great extent. Generally, notwithstanding the 
appearance of a very acute state, if the pustules are not accident- 
ally broken, they may remain for several days unaltered. The 
liquid, however, which they contain, becomes coagulated, forming 
a brownish crust, larger than the pustule, a crust which in the ma- 
jority of cases, becomes drier and drier, and falls only to leave 
behind a cicatrix (pi. 6, fig. 3, shows the pustules accidentally 
opened). Sometimes the pustules enlarge, the liquid becomes 
more abundant, and the epidermis is elevated to a greater extent ; 
then several pustules may be confounded in a single scab, which, 
moreover, is always of small size; but then this scab may also 
cover a superficial ulceration, it is true, but which leaves a cica- 
trix more extensive and more depressed than that of the pustule 
which has passed through its different stages. 

Confluent impetigo has always been called the pustulo-crustaceous 
syphilitic eruption. It is produced by the union of a great num- 
ber of pustules. Ordinarily preceded by indisposition, and even 
by febrile excitement, it may commence by a more or less 
lively redness of the skin, which is also evidently tumefied. 
Soon the red part becomes covered with small purulent collec- 
tions, which are so much the more rapidly confounded toge- 
ther, as they are situated on an inflamed surface. These pus- 
tules remain intact for a very short time only; soon one or 
more large patches appear surrounded by an extensive copper- 
colored areola, and covered with crusts not very prominent, un- 
equal, of greenish color, soft, at least in their earliest stages, con- 
vex at their centre, and encased at their circumference in a soft in- 
flamed tissue, indicating the existence of suppuration^ Beneath 
these crusts, indeed, are grayish superficial ulcerations, with slight y- 
elevated borders, which secrete a sero-purulent fluid, thus forming 
a new crust. As the disease becomes modified, the crusts beeome 



350 VIDAL ON VENEREAL DISEASES. 

more and more desiccated, their circumference consolidated, and 
they are detached by degrees at their edges ; finally, they fall com- 
pletely, and commonly leave an extensive and more or less de- 
formed cicatrix, according to the number of the newly-formed 
crusts. 

This variety may be observed simultaneously at many points ; 
it first appears under the form of distinct patches ; but, unlike the 
serpiginous form, it has no tendency to invade the adjacent parts. 
In its first stages, it is of the size and volume which it should 
maintain throughout its course. If at each renewal of the crusts, 
it increases its dimensions, it is always within very narrow limits, 
as we also find after it cicatrices of greater or less breadth, at differ- 
ent points, near or remote from each other ; but we never find 
those long tracts where the skin is ulcerated uninterruptedly and 
to a considerable extent. 

Syphylitic Ecthyma. — This is formed by small isolated tumors 
having a base of a certain consistence, and a rapidly-formed crust 
which leaves behind a cicatrix, sometimes very superficial, some 
times very profound. There are two well-marked forms of ecthy 
ma, one of which resembles more the pustules of variola in their 
early stages. These pustules are broader than those of impetigo 
they do not, however, exceed in diameter that of an American 
half eagle; they are of a circular, slightly-conical form, some' 
times a little umbilicated, and surrounded by a coppery areola 
These pustules are rapidly developed, and scattered at once over 
a more or less extensive surface of the body, the extremities, 
sometimes appearing very shortly after the primary accidents 
They are filled with a yellowish fluid which readily escapes 
forming a brownish crust, which adheres but slightly (pi. 6, fi-g. 3) 
At the end of one or two weeks these crusts fall, leaving a spot, 
sometimes a cicatrix, but superficial and central. This is the 
acute ecthyma, and may likewise be called the superficial, and is 
the form, in my opinion, which may be most readily inoculated. 
It will be seen that the patient which furnished me the pus which 
I used for this purpose with success, was effected with an ecthyma 
belonging to this first and rarest form. With it we may observe 
other lesions belonging to the first stages of syphilis ; thus, chan- 
cre may still exist, but this is of rare occurrence ; there may be 
mucous tubercles, and rhagades in the region of the anus. 

In the second form of ecthyma, that which in comparison with 
the former may be called chronic, and deep, the pustules are of 
greater breadth ; they may have the diameter of a five-franc piece, 
but they are generally oval with their greatest diameter in the di- 
rection of the axis of the limb on which they are seated, for these 
pustules are ordinarly observed on the extremities, particularly 
the inferior extremities, as the legs. They are not numerous, and 
do not appear simultaneously. Sometimes there is an interval of 
some months between their eruption. 

The pustule in this variety is preceded by a violet-colored spot, 
the epidermis is raised at the centre, and then soon forms a col- 
lection of thick fluid, which seems a mixture of pus and clotted 



SYPHILITIC ERUPTIONS. 351 

"blood. Immediately around this focus there is a livid areola, it- 
self surrounded by a copper-colored border. External to the 
points where the epidermis begins to rise, is a tumefaction which 
causes the centre of the tumor to appear depressed. When the 
pustule bursts, the contained matter partly escapes, whilst that 
which continues to be secreted forms a black crust, which gradually 
desiccates and at length resembles an eschar. This form of ecthy- 
ma likewise resembles, to a certain extent, the bulla resulting from 
the application of an escharotic. If the crust be early removed, 
an ulcer with a grayish base follows, with perpendicular edges, 
around which is a whitish border, formed by portions of the epi- 
dermis which separate the crusts from the circumference of the 
ulcer. 

Instead of removing the crust we leave it to fall spontaneously 
under the influence of progressive reparation, we perceive that 
this crust continues to become desiccated ; it seems to contract and 
to sink down at the centre. The epidermic border to which we 
have alluded, falls off in very small layers, and permits us to ob- 
serve the circumference of the crust which seems to penetrate the 
thickness of the skin. Finally, portions of the crust become de- 
tached at the edges, then they break towards the centre, and when 
separated, a more or less circular and depressed cicatrix remains, 
with a syphilitic hue. 

This is more common than the preceding variety ; it is more 
grave, and is often observed after the appearance of other second- 
ary accidents, after other syphilitic eruptions, such as roseola, pa- 
pulse, and sometimes after iritis. With, or shortly after, the mani- 
festation of this form, we observe the affections of the osseous, 
fibrous, and parenchymatous tissues. We find therefore, that the 
same eruption may be sometimes secondary, and sometimes terti- 
ary, or much nearer to the former than the latter accidents, thus 
presenting us with another argument against arbitary divisions. 

Further still, between the first and second varieties which we 
have described, there may be an intermediate variety. The pus- 
tules then, instead of being distinct, as in the first variety, exist in 
groups, are confluent at certain points, and form a broad crust, 
which strongly resembles that of one of the forms of impetigo ; in- 
stead of leaving scarcely any trace behind as in the first variety, 
or a well-marked and regular depression as in the second, an ir- 
regular cicatrix remains more distinct than in the first, and less so 
than that in the latter form, for this intermediate variety is always 
a superficial ecthyma. 

Inoculation of Syphilitic Ecthyma. — I was the first in France to show 
that the so-called secondary accident might be transmitted not only 
by contagion ,but by experimental inoculation. My experiments date 
from 1849. In speaking of syphilitic varicella I have already reported 
a case of inoculation from a diseased to a diseased person. This 
report forms part of a Memoir which also contains the two follow- 
ing cases, which we are about to relate. This Memoir was read 
before the Societe de Chirurgie, and was published in the Gazette des 
Hopitaux, of 18th and 22d Feb., 1851. As I had truth on my 



352 TIDAL OX VENEREAL DISEASES. 

side, and as I knew that some of the best minds in Germany had 
already confirmed my experiments, and that in France experiment 
■would*' soon decide in my favor, I was guarded in what I wrote or 
spoke. I did not reply to all the objections which were brought 
forward in the Society and published in the journals, but left the 
facts to speak for themselves. The following is a report of the 
case that gave rise to the most excitement. It is one of the inocu- 
lation of ecthyma from patient to patient in the first place, but 
afterwards from the latter to a sound' person. It presents two 
principal features ; 1st, the phenomena manifested by the patient 
who furnished the matter for the inoculation, and who was also 
seen by MM. Piberet and Lafargue, internes of the hospitals in Paris ; 
2d, the phenomena presented by the sound person who was inocu- 
lated, and which have been reported by himself. 

Case 1. — Inoculation from patient to patient, and from the patient 
to a sound person. 

A servant, set. 23, of bilious-sanguine temperament, was admitted 
at the Hopital du Midi on the 28th October, 1849, and occupied 
bed Xo. 30, Ward 11. Had always enjoyed good health, and was 
born of healthy parents. Six weeks since he had a chancre on the 
right side of the frenum ; this is now cicatrized, and only a slight 
induration remains. Eight days after it had healed the patient 
suffered from itching about the anus, which subsequently became 
completely surrounded by mucous tubercles. Ehagades exist in 
the mucous folds. Simultaneously with these phenomena, appeared 
an eruption on the skin, which was preceded by redness on the 
surface ; soon followed little pimples, papules, and three or four days 
aftenvards, pustules. This eruption was preceded by febrile ex- 
citement. The diameter of the pustules varied from that of a lentil 
seed to that of a half eagle (American) piece. They commenced 
on the head, and became irregularly scattered over the trunk and 
extremities, and were particularly numerous on the right side of 
the chest. The inguinal and cervical glands were enlarged. The 
circumference of the anus is covered with mucous tubercles ; there 
are rhagades, and a fetid puriform discharge. No infundibuliform 
disposition. The patient is tormented with supra-orbital cephalal- 
gia, which increases at night, and continues very intense until 
morning. Severe pains are felt in the shoulder joints, as well as 
in those of the lower extremities. The head is covered with crusts, 
which are easily detached. It has been stated that the pustules 
existed in greatest number on the right side of the chest ; there 
were also some on the abdomen. Altogether, there are thirty well- 
marked pustules on the trunk ; they are more distinct on the upper, 
and on superior and anterior parts of the lower extremities. The 
broadest are on the chest. All are surrounded by a coppery-red 
circle. All contain pus ; most are covered with a crust, the color 
of which varies; some are dark, others white, others squamous 
and adherent ; others, in fine, are of a yellow color, more or less 
distinct. All are surrounded by a circle, the color of which has 
already been mentioned, and are seated on a tissue somewhat 
tumefied. Some of the pustules are covered by a grayish crust, and 



ma 



SYPHILITIC ERUPTIONS. 353 

seem to be of more recent development ; they fill with well assimi- 
lated pus. 

On the 28th October, 1849, punctures with a lancet charged with 
pus from one of these latter pustules, situated on the right side of 
the chest, were made on the inferior and internal part of each thigh 
of the patient. On the 29th, an elevation appeared at the point? 
punctured, which gradually assumed the characters of the pustules 
on the trunk. Matter was taken from the inoculated pustules, and 
inserted into the upper and inner surface of the thighs. The same 
results followed as in the first inoculation. 

Nov. 1st. M. Boudeville, interne in pharmacy, who had never 
had the slightest venereal symptom, and who had an excellent 
constitution, offered to submit to the inoculation. Matter was 
taken from a pustule on the left side of the thorax of the above- 
mentioned patient, a pustule which had never ulcerated, which was 
completely intact, and covered only with a grayish crust. With 
a clean lancet charged with this pus, inoculation was made on the 
inferior part of the palmar surface of the left fore-arm of M. Boude- 
ville ; with pus from another pustule in the same region, and as 
recent as the former, inoculation was made on the right fore-arm.* 

The patient, who entered the hospital on the 21st of October, 
1849, I could not prevent from leaving on the 24th November of 
the same year ; however, he had been examined for nearly a month 
by the students attached to the hospital, by those who followed 
my service, and by the members of the German Medical Society, 
among whom was M. Eobert de Weltz. MM. Surmay, and de 
Castelneau were invited to visit and to examine both this patient 
and the student of pharmacy. As I foresaw that this case would 
make some noise, it was my wish, as may easily be understood, 
that the patient should himself note the circumstances of his case. 
I therefore requested him to keep a record of what passed. But 
as it was also my opinion that a student in pharmacy could not be 
competent to fulfil all the conditions required of a medical observer, 
I myself watched the effects of the inoculation. The following is 
the student's report, unaltered : 

" On the day following the inoculation, the 2d November, traces 
of inflammation began to appear. In the evening I felt dull pains 
analogous to those accompanying suppuration. 

" On the 3d, a papule of about four-fifths of a line in diameter, 
occupied the centre of the red circle ; until the 5th November this 
papule remained stationary. The inflammatory circle followed the 
same course, and extended some trifling distance beyond it ; the 
papule now became remarkably convex and covered with a cracked, 

* It is important that the reader take note, that matter for the inoculation was 
taken from three different pustules: 1st. From the right side of the thorax, to 
inoculate the patient himself; 2d. From the left side of the thorax, to inoculate the 
left fore-arm of the student; 3d. From the same region, to inoculate the right tore- 
arm of the same student. So that, if it be pretended that the matter used for the 
inoculation was taken from a chancre, we must admit the existence of three 
chancres on the thorax, and, as a matter of course, the other pustules scattered over 
the body, exactly resembling those on the chest, must all likewise have been 
chancres ! 

23 



354 YIDAL OX VENEREAL DISEASES. 

grayish" crust, and beneath this crust was a thick, grayish- white 
pus, clearer throughout than that used for the inoculation. This 
pus was several times discharged in consequence of the friction of 
the linen against the pustule, but it was immediately reproduced. 

" At every period of the eruption I suffered severe local pain, 
which sometimes extended along the arrn. I discovered no symp- 
toms of general disturbance. 

"During the first eight days I perceived a hind of circular in- 
flammation, surmounted by a small papule which broke out on 
the external and superior surface of the thigh ; it disappeared in 
the course of four or five days. It is probable that at this part of 
the thigh there was seated a pimple chafed by the clothes, and that 
during my sleep, the fore-arm having been brought in contact 
with it, took up a small quantity of the pus, which gave rise to a 
pustule. 

" Towards the 15th of Nov. the inflammation ceased ; the pus- 
tules subsided and cicatrized ; their surface soon became flat and 
laminated ; the puncture made by the lancet left an infundibuliform 
scar of a brownish-red color, and presenting whitish scales, like 
those of lichen. 

" Such was the condition of things until the 5th of December, 
thirty-five days after the inoculation, at which time a change oc- 
curred ; an inflammation supervened, and two consecutive pustules 
appeared occupying precisely the situation of the first, and I suf- 
fered only a severe pain in the same locality* Pressure, even at a 
considerable distance, produced intense pain. 

"The cicatrization was here very slow on account of the very 
copious suppuration, especially in the pustule on the right arm, 
which had been irritated by one of the pins used in the dressing. 
Cicatrization was not completed until the 20th Jan. 1850. 

" M. Yidal, on the first cicatrization, advised me to submit to 
treatment. This advice I did not follow, thinking that the ex- 
periment was not sufficiently conclusive from the manifestation of 
local phenomena only, and I determined to await the development 
of symptoms of general infection before I subjected myself to 
treatment. Up to the present time, March 8th, 1850, one hundred 
and twenty-eight days from the date of the inoculation, no symp- 
tom of general infection has appeared. 

" This report is handed to M. Yidal, March 28th, 1850. 

" BOUDEYTLLE." 

Such is M. Boudeville's account of the symptoms produced on 
his own person, and which may be regarded as the result of gen- 
eral infection. The following is the report presented to me by 
the student in pharmacy on the 10th August, 1850 : 

*Thus the first pustules, those which immediately folio-wed the inoculation, 
lasted about fifteen days ; and about twenty days after their complete cicatriza- 
tion, pustules appeared spontaneously much smaller than the first, and, as M. Bou- 
deville goes on to say, they lasted forty-five days. As to the seat of the second 
pustules, it is necessary to be precise on this point ; the first were in the middle 
of the anterior surface of the fore-arm, the second appeared a little nearer the bor- 
der of the radius at a point on the circumference of the first, with the cicatrices 
of which they became confounded. 



SYPHILITIC ERUPTIONS. 355 

" Flat lenticular tubercles appeared on my scalp, a posterior and 
superior cervical ganglion became enlarged, and finally there was 
alopecia. About the 25th of April I experienced some difficulty 
in swallowing, and the mouth began to inflame ; a roseola appear- 
ed on the body which lasted for three or four days, and finally 
mucous tubercles became developed on the pillars of the palatine 
arch. Then, for the first time, I submitted to mercurial treatment. 
At first I took but one pill of the proto-iodide of mercury ; but 
rheumatic pains and nocturnal cephalalgia induced me to take two, 
three, and afterwards four a day. The pains having subsided, I 
gradually reduced the number to one a day, which I still continue 
to take. 

u The mucous tubercles in the mouth are now cicatrized ; a 
brick-colored tint remains in a circle completely arrested, and in 
which the pustules were formerly seated. 

"No other symptom has appeared. 

" Ch. Boudeville. 

"Paris, August 22d, 1850." 

I repeat that this case should be examined under two different 
points of view : 1st. The details concerning the patient, whose 
body was covered with pustules ; these were collected by MM. 
Piberet and Lafargue, internes of the hospitals, and who are still 
in Paris, whose education and character are known to several of 
the chief physicians in the hospitals of Paris. This part has not 
been, nor can it be, directly attacked. 2d. The details in the sec- 
ond case were furnished by the student in pharmacy who was 
inoculated, which, when taken in connection with those given by 
other persons, seemed to show a contradiction with the first.* 
Hence arises an obscurity as regards this second part of the case 
which it has been attempted to cast over the whole so as to destroy 
its value. But the conclusion of M. Boudeville's report has not 
been attacked ; it is that which establishes the fact that a student 
in pharmacy has been infected with syphilis from inoculation per- 
formed by myself. Thus, two points are incontestably established. 
1st, that the patient who furnished the pus had secondary pustules, 
and that it was from these pustules that I procured the matter 
with which I inoculated the student ; 2d, this inoculation produced 
constitutional infection (la verole). For my own part, I have no 
doubts on the subject. The question is settled, for I have not to 
prove the possibility of transmitting such or such a form of syphi- 
lis, but of one of its forms. Now I have transmitted constitutional 
syphilis. The nature of the lesions produced on both fore-arms 

*The discrepancy found in the second case of M. Boudeville, consists in the re- 
port of a glandular enlargement in the axilla? during the existence of the pustules 
on the fore-arms. low, at page 35*7 et suiv, it will be observed, that in the first 
case of this student, dating March 29th, 1850, when the extremities wove no longer 
affected, nothing indicated this glandular enlargement which M. Ricord had al- 
ready noticed in this student! I have besides proved, in several parte of this 
work, that adenitis is of no particular value in forming a diagnosis. In this ease 
the enlargement of the axillary glands mia;ht have been the result of the general in- 
fection. "Of course, in a work like the present, I refrain from commenting upon 
the conduct of persons. 



356 VIDAL ON VENEREAL DISEASES. 

of the student have been called in question. It is pretended that 
they were chancres. This is of but little consequence. The 
question, I repeat, is n©t whether a secondary accident may trans- 
mit an identical form of disease, but whether it can transmit any 
form of syphilis. If the student had had at first two chancres on 
the form-arm, this would prove that with the matter from sec- 
ondary ecthyma we may produce chancres, a fact which would 
still more compromise the doctrine of my opponents. But there 
was nothing of the kind, for we see the pustules which imme- 
diately followed the inoculation of the student, lasting for fifteen 
days ; they afterwards completely disappeared, and twenty days 
after this disappearance, this complete local cure without any 
traces being left, they re-appear spontaneously, in the absence of 
any exciting cause, and the pustules are larger than before. These 
pustules lasted for forty-five days ; they appeared not exactly at 
the centre of the cicatrix of the first pustules, but at a point of 
their circumference. Is such the course of a chancre? No; 
when the reparation of a chancre is once complete, it is not re- 
produced. Before another chancre can appear, there must be 
another inoculation. This is the doctrine which M. Bicord in 
particular professed. Besides, I have already remarked that I 
was not satisfied to trust the entire report of the case of the student 
himself. I myself watched its progress. 

Further still, in so important a case I was desirous of having 
the opinion of a colleague versed in such matters. I therefore 
took this student to M. Cazenave, of the hospital St Louis ; I con- 
sulted him as to the nature of the pustules and the treatment best 
to be pursued. M. Cazenave, after a careful examination and 
without any previous instruction on our part, declared that the 
pustules on the fore-arm of M. Boudeville were two syphilitic ecthy- 
matous pustules, that he was fully satisfied on this 'point, and he advised 
a mercurial treatment. It was not until then that both M. Boude- 
ville and myself declared that these pustules were the result of 
inoculation with the pus taken from two ecthymatous pustules on a 
patient in the Hopital du Midi. This led M. Cazenave himself to 
experiment, and shortly afterwards he published a case of success- 
ful inoculation with the matter of a syphilitic ecthyma. 

But it was not sufficient to have myself proved the inociilability 
of secondary accidents ; it was not enough to see my experiments 
confirmed by writers on syphilis, who it was supposed coincided 
in my opinions, stronger evidence was required, and it was neces- 
sary that experiments should be undertaken by those whose senti- 
ments were in sympathy with my opponents. In this point of 
view, the report of the two following cases is possessed of great 
importance. 

Being under the necessity of taking a journey to the South, my 
colleague, M. Puche, was willing to take charge of my service, and 
made the following experiment, the details of which were care- 
fully collected by my former interne, M. Dumenil. 

Case 2.— Ward 11, bed No. 26 ; admitted 30th October. Tem- 
perament sanguine; constitution very robust; embonpoint con- 



SYPHILITIC ERUPTIONS. 357 

siderable. Aged 24 years. Fifteen months before, this patient 
had had chancres. He was treated by M. Vidal, at the office of 
consultation, at the commencement of his disease, and took but 
twenty mercurial pills. The chancres were cauterized by another 
physician. He never had any glandular enlargement more decided 
than that which now exists. During the first weeks of the exist- 
ence of his chancres, he had sore throat, but he was subject to this 
before. JSTo rheumatic pains ; no cephalalgia, no alopecia. In the 
left groin is a superficial gland somewhat enlarged and indolent. 
The patient declares that it has always existed. Behind the right 
sterno-mastoideus is a gland very much enlarged, which likewise 
existed before his venereal attack. Traces of chancres are found 
on each side of the frenum ; the cicatrices are depressed but not 
indurated. Blennorrhagia is present, and this is of three months 
standing. In front of the right internal malleolus is a brownish 
cicatrix produced, according to the patient, by his boots, some 
three months since. It should be remarked, that he had worn 
these boots for a long time, and they had never caused the slightest 
pain. This ulceration has the same characters as that seated still 
higher on the leg. It healed spontaneously in the course of fifteen 
days. On the anterior and external surface on the middle third 
of the right leg are five ulcerations covered with a black,- thick 
crust, which are also of three months' standing. These ulcerations 
are of a circular form ; one of them is elongated in a vertical direc- 
tion ; they are deep, with prominent, perpendicular edges ; a sani- 
ous pus covers their base ; a deep-red areola four lines in diameter, 
surrounds them. But slight induration is felt at their base. Two 
of these, ulcerations resulted from the fall of a piece of wood, which 
produced a solution of continuity. The others appeared spontane- 
ously, in the form of little white pimples. Four or five small pus- 
tules exactly resembling those of acne are scattered over the leg. 
The diameter of these ulcers above mentioned is about two lines. 

Nov. 1st, 1850. Inoculation was performed on the anterior sur- 
face of the right thigh, with pus taken from one of the ulcers which 
we have described, and which succeeded to the contused wound. 
The puncture was made with a lancet carefully cleaned for the 
purpose. The point inoculated was covered with a watch-glass. 
Iodated water, § iss. ; calomel and jalap, grs. xv.; dressings to the 
ulcers of straps of Yigo plaster. 

2d. The point inoculated is covered with a sero-purulent fluid 
to the extent of about- two lines. On gently removing this fluid 
with a piece of linen, without chafing, the epidermis is found ele- 
vated. The surrounding parts present to the touch a sense of 
engorgement, for the space of about one-third of an inch ; there are 
no pains. 

3d. A small pustule, of the size of a pin'shead, appeared about 
one and a half lines above the punctured point ; it is traverse J by 
a hair. Another small pustule, somewhat larger than the other, 
exists at the distance of two-fifths of a line external to the inoculated 
point. On the latter itself, the skin becoming slightly tense, is a 
fissure resembling an elongated ulceration ; within this fissure, for 



358 VIDAL ON YENEREAL DISEASES. 

the space of four-fifths of a line, is a yellowish surface, which 
appears to be produced by dried pus. The surrounding parts are 
red, not tumefied, and covered with a little dried purulent matter 
like a layer of varnish ; no pains. 

4th. The redness extended over a space of about two-thirds of 
an inch in diameter. At the centre is an ulceration of four-fifths 
of a line in diameter, covered with a crust. No pain. For the 
last twenty-four hours the point inoculated has not been covered 
with the watch-glass, which is no longer applied. 

5th. The ulceration appears to be almost entirely healed ; the 
redness diminishes, and the engorgement has almost completely 
disappeared. 

6th. There exists a light grayish crust on the point inoculated. 
Kedness and engorgement the same. 

7th. The ulceration yields a little serous fluid ; it has not in- 
creased in extent. 

8th. Yellow crust, depressed in the centre, of cup-like form, and 
about two lines in diameter : slight engorgement beneath the crust ; 
redness remains the same. 

9th. Deep ulceration at the centre, superficial at the edges, about 
a quarter of an inch in diameter ; slight engorgement and redness. 

11. Crust nearly one-third of an inch in diameter, bulging at 
the centre, of a brown color, and surrounded by a red areola. For 
the space of four lines around the crust, there is no sensible en- 
gorgement. The ulcerations of the leg have a tendency to cica- 
trize ; the bottom is elevated, the edges sunken, and the granula- 
tions covering them of a good aspect. 

12th. Crusts of good aspect, prominent ; no engorgement of the 
subjacent tissues. Eedness the same ; itching sensations, but no 
pains. 

13th. The crust, when removed, appeared thin at its edges. At 
its centre was found a thickened portion which projected into the 
centre of the subjacent ulceration. The latter, superficial at its 
circumference, was about four-fifths of a line in depth at its centre ; 
the surface of the ulceration is of a rosy hue, and secretes but little 
pus ; no glandular engorgement. 

14th. The crust has formed again, and presents the same charac- 
ters as before, no more redness nor engorgement. The patient left 
during the day in consequence of his disobedience. 

22d. He presented himself to me ; the ulceration remains, and is 
covered by a thick grayish crust, bulging at its centre to the ex- 
tent of a quarter of an inch, and is two lines in breadth ; desqua- 
mation of the epidermis throughout to the extent of two-thirds of 
an inch ; slight engorgement ; no pains ; pressure on the crust 
causes the discharge of a drop of pus. 

The report of M. Dumenil here concludes. This student ordered 
the application of a cataplasm to the pustule. According to the 
patient, the crust separated the next day, and left behind a super- 
ficial ulceration, which cicatrized in five days afterwards. 

Dec. 4, 1850, the patient presented himself to me. I observed 
sunken cicatrices at the lower part of the right leg, at the point 



SYPHILITIC ERUPTIONS. 359 

where the -ulcerations had existed ; they were surrounded by an 
areola of a brownish, coppery-red color. On the thigh, the cica- 
trices of the inoculated pustules presented the same characters ; it 
was somewhat larger than a ten-sous piece. The shin around it 
was of a very brown color. 

This case shows us an inoculated pustule, which seems to have 
aborted on the sixteenth day, and which afterwards reappeared 
and became of larger size. If the patient had been abandoned at 
the first period of the inoculation, we should have inferred that the 
latter had not succeeded. 

Case 3. — I have already stated that M. Cazenave has expert 
mented on a patient having a tubercular syphilitic eruption ; a 
pustule of ecthyma broke out on his thigh, and the matter from 
this pustule was successfully inoculated on both fore -arms of the 
patient. The case is reported by M. Cazenave, with all its minute 
details, in the Annates des maladies de la. peau et de la syphilis. He 
states, very positively, that the patient was exactly in the condi- 
tion to favor the success of the inoculation. There was no primary 
accident ; the patient was repeatedly and thoroughly examined 
with the speculum, before the experiment, and again at the mo- 
ment when the inoculation was performed. The results of the 
latter were closely watched by several persons. It may be ob- 
jected, says M. Cazenave, that a chancre, in this case, was mistaken 
for an ecthyma. If so, says the physician of St. Louis, it is one of 
those arguments to which it is impossible to reply. 

In 1851, my colleague, M. Kichet, then one of the surgeons of 
the Lour cine, informed me that he had succeeded in inoculating a 
consecutive syphilitic ecthyma. He also made several other 
writers on syphilis acquainted with the same fact. I accepted the 
invitation of my worthy colleague to witness the case, the details 
of which have been recorded by a distinguished interne, M. Du- 
breuil. 

Case 4. — B. Nathalie, get. 21, dressmaker, admitted July 5, 
1851, into Ward St. Alexis, Bed No. 9, Hospital Lourcine, service 
of M. Richet. This girl, of a lymphatic temperament, a very strong 
constitution, menstruated for the first time at the age of seventeen ; 
it was long before menstruation became regularly established, but 
she now suffers no pain at these periods ; the discharge is abundant, 
and lasts for six days. Has never been pregnant, nor been affected 
with leucorrhcea. Previous to her admission to the hospital she 
had never been attacked with syphilis. Three weeks before her 
admission, she discovered several little pimples on the vulva, and, 
as they were attended with considerable itching, she scratched 
them until they bled. This produced small wounds, to which 
emollient lotions only were applied. They soon healed, but large 
flat tubercles soon appeared at these points, which attention to 
cleanliness was not sufficient to remove. 

Examination. — Mucous tubercles are scattered here and there in 
large numbers both on the labia majora and minora ; among them 
were two of smaller size situated at the fourchettc, they were ul- 
cerated on their surface, and appeared to be two chancres in pro- 



360 VIDAL ON VENEREAL DISEASES. 

cess of transformation. Nothing in the region of the anus, and 
neck of the uterus, is sound Slight vaginitis. Skin healthy ; no 
frontal cephalalgia ; no osteocopes. 

Treatment — One pill of pro to -iodide of mercury, and two injec- 
tions of alum daily ; two alum tampons, and two baths (general) 
twice a week. 

July 8th. The mucous tubercles are cauterized with a concen- 
trated solution of the nitrate of silver. M. Eichet observed before 
the cauterization that no trace of chancre remained. 

9th. Patient complains of having suffered during the whole 
night at the internal and superior parts of the left leg. At the 
point designated, a small white pimple was discovered, formed by 
the elevation of the epidermis, and resting on a red inflamed 
base. 

12th. This pimple has become transformed into a fine pustule of 
ecthyma ; this pustule rises about four-fifths of a line above the 
surface of the skin ; it is about five lines in diameter ; its acuminated 
summit is formed by an elevation of the epidermis through which 
we detect by its transparency a fluid enclosed in the pustule. 
The point where the epidermis is raised, that is, for a radius of 
two lines in extent, has a yellowish aspect, the base of the pustule 
presents a bluish and violet hue, pressure at this point is very 
painful, and gives rise to a sensation of induration and tension. 
The adjacent skin is of an erysipelatous redness, disposed in the 
form of an areola around the pustule ; this areola gradually fades 
as we leave the pustule, its diameter in every direction being 
about one and two-third inches. The patient is confident that at 
this point there has been neither excoriation nor puncture. Be- 
sides, the epidermis covering the pustule appears to be prefectly intact 
throughout 

M. Eichet again examined the patient, and discovered that no 
trace of the chancre remained on the vulva, and called our atten- 
tion to the fact that the effect of a single cauterization had been 
to diminish the size of the mucous tubercles one half, and that 
they were all shrivelled and sunken. Then having punctured 
the top of the pustule on the leg, there issued a fluid somewhat 
analogous to a reddish, slightly opaque serum ; a little drop of 
this fluid was gathered on the point of a lancet, and inoculated at 
a corresponding point of the opposite extremity. To protect the 
point inoculated from the vaginal discharges, it was covered with 
a watch-glass fastened by means of a broad strap of diachylon 
plaster applied one and a half times around the limb, over which 
a bandage was applied ; the patient was confined to her bed. 

14th. The ecthymatous pustule has burst during the night, 
and discharged an abundant sanious fluid, which stained the 
linen red. This produced a hollow cup-like ulceration, with 
ragged edges, and a grayish base. A violet-colored areola of an 
inch in diameter surrounded it, leaving here and there exposed 
little whitish points formed by small collections of pus under the 
elevated epidermis. An extensive erysipelatous redness sur- 
rounded the whole. Before the pustule opened, the patient expe- 



SYPHILITIC ERUPTION'S. 361 

rienced throbbing, shooting pains, from which she suffered so 
much as to prevent sleep. Now the pain has ceased. On the 
other hand, at the point of inoculation, the epidermis is raised, 
forming a small vesicle of the side of a pin's head ; this vesicle is 
filled with a liquid which appears white, limpid, and transparent ; 
it is surrounded by a small inflammatory areola. Mercurial treat- 
ment still continued. 

16th. The ulceration which has succeeded to the pustule of 
ecthyma is about four lines in extent in all directions ; its edges 
are irregular, but have no tendency to become everted ; they are 
smooth,* circular, and the commencement of cicatrization is already 
apparent. The base, covered at first with a whitish false mem- 
brane, begins to become clean. At the seat of the inoculation, the 
vesicle produced by the elevation of the epidermis, has acquired 
the size of a lentil seed ; it presents a whitish and slightly -yellow- 
ish aspect, and is no longer transparent The surrounding inflam- 
matory areola increases in size ; and the patient says that during 
the night she suffered shooting pains in this situation. 

17th. The pustule produced by the inoculation rests upon an 
indurated base ; M. Eichet punctured it with a lancet, gathering 
on the point of the instrument a little of the purulent fluid which 
escaped, and inoculated it on the right arm. 

18th. The ulceration which succeeded the first pustule is in 
process of reparation, the base is of a fine red color, and is nearly 
on a level with its edges. This pustule has remained sunken 
since the day when it was first opened. The inflammatory areola 
surrounding it is diminishing in size, but the base on which it 
rests is indurated, and pressure with the fingers gives exit to a 
drop of pus, mixed with reddish streaks, and the patient suffers 
pain. The second inoculation appears to have succeeded on the 
arm ; the little vesicle formed by the elevation of the epidermis is 
filled with a white and slightly-opaline fluid. A rose-colored cir- 
cle surrounds it. Patient states that during the night she felt at 
this point an itching, stinging sensation. 

22d. The ulceration which followed the opening of the pustule, 
and which seemed for a time to have healed, again cracked and 
assumed a palish hue, the circumference always remaining violet 
colored ; it rests upon a broad indurated base. 

The pustule produced by the first inoculation has entirely healed, 
but an indurated portion of skin about two lines in diameter, and 
perfectly limited at its circumference, constantly remains. The 
pustule on the arm broke during the night ; in its place a yel- 
low, and even a somewhat transparent crust is found, which is 
formed by the desiccation of the fluid contained in its cavity. 
The inflammatory areola has completely disappeared. The mer- 
curial treatment is suspended inconsequence of incipient stomati- 
tis. 

30th. The ulceration which succeeded to the first pustule pre- 
sents a pale violet aspect, and seems no longer inclined to cicatrize. 
It rests upon an indurated disk, which surrounds it at every point. 
The focus of induration, sole vestige of the first pustule produced 



362 VEDAL <M VENEREAL DISEASES. 

by inoculation, constantly remains. There is no longer any mark 
upon the arm. 

Aug. 2d. The ulceration which succeeded to the opening of 
the pustule of ecthyma begins to cicatrize. The indurated focus 
still exists on the other leg, but its extent is greatly diminished. 

21st. The ulceration which followed the opening of the first 
ulcer has not yet completely cicatrized, but appears as if soon about 
to be completed. The indurated portion remaining at this point, is 
reduced to a small nodule about the size of a pin's head. During 
the interval from Aug. 21st and Dec. 13th, some patches of pso- 
riasis appeared on the palmer surface of the hands ; M. Gosselin 
who now acted in the place of M. Eichet, made the patient follow 
a mercurial treatment during the six weeks, and discharged her 
perfectly cured on the 13th Dec, 1851. 

M. Dubreuil terminates his remarkable report as follows : " This 
case shows us that secondary syphilitic ecthyma, notwithstanding 
all that has been lately asserted to the contrary, may sometimes be 
successfully inoculated."* 

As might have been supposed, this case has met with the hack- 
neyed objection, which has been urged against every reported ex- 
ample of the inoculation with other products than those of chancre. 
M. Eichet having successfully inoculated, could not have used mat- 
ter from a secondary accident, because it is a law that secondary 
accidents cannot be inoculated. The pustule, therefore, from 
which the matter was taken must have been a primitive pustule, a 
•chancre. Whence came this chancre ? demands M. Eichet. The 
female inoculated was sojourning at the Lourcine, and had no pri- 
mary accident when the ecthyma appeared on the leg. Then a 
person in the same ward is accused, from whom the chancre pus 
was taken. But, replied M. Eichet, there were no chancres in the 
ward. 

Those who have examined the facts in a purely scientific point 
of view, have long since become satisfied. Thus my experiments 
have been confirmed in Germany by physicians who were un- 
acquainted with what I had attempted. M. Cazenave has experi- 
mented and succeeded as well as myself. At the Lourcine, two 
colleagues, not at all interested in what I was doing, experiment- 
ed independently ; one of them, M. Bouley, succeeded in producing 
a mucous tubercle in a woman too who had already had syphilis, f 
and the other, M. Eichet, successfully inoculated a secondary ec- 
thyma. Those acquainted with the state of medical matters in 
Paris, can comprehend the importance of these facts, coming as 
they do from such sources as MM. Eichet and Bouley. Both 
were at the head of the service at the Lourcine, a hospital opposed 
to the doctrine of the inoculation of secondary accidents : both have 
a reputation for probity, and for intelligence; which cannot be ques- 

* This report, "with the exceptions of the conclusion, -was read at the Lourcine 
by M. Dubreuil in the presence of the patient of M. Richet, under whose observa- 
tion it was made, in the presence of several students of the Lourcine and my interne, 
M. Pellagot, who accompanied me. 

f Vid. the chapter on Mucous Tubercles. 



SYPHILITIC ERUPTIONS. 363 

tioned. Nothing now is wanting but an admission from Hunter, 
from him who promulgated the error which I now combat. Well, 
we shall see that Hunter himself has recorded in his work a con- 
clusive example of the inoculation of the secondary accident ! At 
page 524 of his Traite des maladies veneriennes, translated by M. 
Eichet, first edition (Amer. Ed. of Hunter by Babington, p. 241. — 
GK C. B.), are these words which I carefully copy : 

" To ascertain whether her secondary ulcers were infectious, 
that is, whether the matter of them would have the specific effects 
of venereal matter, she was inoculated by some matter from one of 
her own ulcers, and with some matter from a bubo of another person 
where mercury had not been used. This was done September 18, 
1782. Sept. 19, the puncture where she was inoculated with her 
own matter gave her pain three hours from the time of inoculation, 
and the day following inflamed a little. The other had not then 
inflamed at all. Sept. 20, both the punctures had suppurated, and had 
the appearance of a small pox pustule ; they spread consider alny." 

Here we have two pustules exactly resembling those of variola, 
produced, one from pus taken from a secondary, the other from that 
of a primary accident. The secondary was therefore inoculated as 
well as the primary accident. This fact is incontestable. But, then 
comes the system which, considering itself greatly compromised, 
thinks to save itself by pretending that the two pustules were not 
cured by the same means, that they did not terminate at the same 
period ; Hunter therefore concludes, that secondary accidents can- 
not be inoculated. As if the pustules produced by inoculation 
with the pus of chancre were always cured by the same means, 
and always at the same time ! I have quoted Hunter, and have 
referred to the page. I beg the reader to peruse the report from 
which I have given an extract ; it is very remarkable on other ac- 
counts. Further, I shall be able to show that Hunter frequently 
contradicts himself. This will be done in the approaching chapter. 
"We insert in this place one more case reported by M. Bossen, one 
of my former internes : 

B. (Alphonse) set. 17, carpenter, of a lymphatic temperament, 
constitution not very strong, admitted at the Hopital du Midi, 
Ward 11, No. 11, March, 1851, and left on the 18th April of the 
same year. 

Six months before, he had blennorrhagia ; cured in a month 
spontaneously. On the 8th or 9th of March, 1851, the patient 
discovered a syphilitic eruption, for which he entered the hos- 
pital on the 17th March. When examined, we found the follow- 
ing characters. 

Abdomen and Thorax.— There are here slight red elevations, 
conical-like papules, surrounded at their base by a red areola. 
The summits of some of these are covered by a small purulent 
vesicle containing whitish pus. On several, a small crust easily 
detached covered a small, brownish-red elevation. The erupt ioti 
is sparse and scattered, and the pustules are irregularly spread 
over the surface. 

Pubes.— On the pubes, in the midst of the hair, are thin, lamel- 



364 VTDAL ON VENEREAL DISEASES. 

lated, yellowish crusts ; some are of a greenisli color, others are 
soft, others friable. Among these crusts are scattered some acu- 
minated, very small, and prominent pustules ; the base of those 
which, from their isolation, permitted the fact to be noticed, was 
not surrounded by an inflammatory circle. They contain an 
opaque and purulent fluid. 

Left Axilla. — The eruption here presents nearly the same char- 
acters as on the pubes ; the pustules are very numerous, and at 
different points among them, are seen isolated crusts. The surface 
of the skin covered by the eruption is surrounded by a red circle. 
Over the scapular regions the eruption was of the same nature ; 
only it is a little more discreet. Crusts, pustules, &c. 

Bight Cheek. — For a space of about the width of a five-franc 
piece are yellowish crusts, resulting from the desiccation of the 
pustules, which are very confluent at this point. They are 
wrinkled, and of a yellowish-green color. On detaching a portion, 
the sxin is found red and shining. A sero-purulent discharge 
issues from the surface covered by this crust, and permits us to 
raise the latter at all points of its circumference. It seems to ad- 
here slightly to the skin. 

On the posterior part of the trunk and nates, exist irregularly 
scattered pustules. They have the same character as those on the 
thorax, with the exception of some which I shall describe more 
particularly. One of these is on the internal and superior part of 
the left nates. The diameter of its base, which is not indurated, 
is somewhat less than that of a half- dime piece ; summit a little 
elevated, and covered with a crust not quite so broad as the base, 
and appears as if formed of super-imposed scales; the crust is 
somewhat raised by a thin layer of yellowish-green pus, is thick, 
and has a coppery -red areola {ecthyma). The matter from this 
pustule was used to inoculate the anterior surface of the right fore- 
arm. Two punctures were made. 

On the external part of the right thigh is another broad circular 
elevation, with a prominent reddish base. Around and beneath 
this elevation is a feeling of induration, which seems to extend 
through the subjacent cellular tissue. The summit, more acute 
than that of the pustule last described, is covered with a yellowish 
crust of less thickness, and raised by a yellowish pus. Pus from 
this pustule was inoculated on the left fore-arm. These inocula- 
tions were performed in the presence of MM. Chaussit, Auzias, 
Turenne, and the students in the service ; they were made on the 
9th of April, 1851. The punctures were left exposed to the air 
during part of the day. 

April 10th. On the right fore-arm, the punctures are surrounded 
by an areola, the diameter of which is equal to that of a half-dime 
piece. On the left fore-arm exists a red point : areola not more 
than half so large as in the other puncture. 

11th. On the right fore-arm are two acuminated pustules, of the 
size of a lentil seed ; areola very red, and of the diameter of a half- 
dime piece. On the left fore-arm the pustule is smaller, and conical 
shaped ; areola of a rosy hue, and two or three millimetres in width. 



SYPHILITIC ERUPTIONS. 365 

12th, 13th. No change. 

14th. Patient has chafed right fore-arm ; surface reddish, and 
bloody. On the left fore-arm, the pustule is surrounded by a 
brownish-red areola, smaller than on the 11th. 

15th. A new pustule has appeared on the right fore- arm, of large 
size, and seems formed by the union of the two first. Areola of a 
brownish red, diameter of a twenty -centime piece ; crust yellow, 
slightly adherent, and raised by a thin layer of pus ; base not in- 
durated. On the left arm, the inflammation is of a browner color, 
and seems to spread. 

16th. The pustule on right fore-arm presents the same characters 
as the first. That on the left seems as if about to disappear. Are- 
ola brown, and from two-fifths to four-fifths of a line in diameter ; 
the epidermis raised by the pus appears to be in folds. The crust 
covering the right pustule was removed in the presence of MM. 
Auzias and Chausit, and beneath was found an ulceration with a 
reddish base. In its centre is a grayish portion formed by con- 
crete pus. 

17th. The crust on the right arm has been reproduced, with the 
same characters as the old. On the left, the inflammation seems 
to have assumed more activity. Areola larger and redder. 

18th. On the right arm, the diameter of the areola remains the 
same, though somewhat browner; in its centre is a thin, yellow 
crust, formed by solidified pus. The pustule on the left arm is 
broken ; there remains a thin, yellow, and very broad crust. The 
areola has the same characters as the old. 

The patient left, on the 18th of April, to enter the hospital St 
Louis. He was followed by M. Chausit, who has sent me the fol- 
lowing note : 

"The patient, on whom M. Yidal successfully inoculated two 
pustules of secondary ecthyma, entered the hospital St. Louis the 
day after leaving the Midi. Five days afterwards the crusts on 
the fore-arms separated and the ulcerations cicatrized. I saw him 
on the 28th of April ; I found a well-marked, depressed cicatrix, 
of the diameter of a lentil seed, at the point where the puncture 
was made on the left fore-arm ; this cicatrix was surrounded by an 
areola of a coppery -red, brownish color, the diameter of which was 
about one-third of an inch. On the right fore-arm, the cicatrix, 
instead of being depressed, projected a little on the contrary, like 
a tubercle. Same copper-colored areola. Brownish red spots 
marked the places occupied by the first pustules, but none of them 
presented a notable cicatrix. Patient left the hospital St. Louis on 
the 1st of May." 

SYPHILITIC TUBERCLE. 

The syphilitic tubercle appears in the form of a small, full, tense 
tumor, containing neither serum nor pus. This small tumor or 
tubercle is more or less elevated above the level of the skin. 
Sometimes they are scattered in large numbers over an extensive 
surface, sometimes, on the contrary, the number is limited and 



355 VIDAL ON VENEREAL DISEASES. 

confined to a small portion of the surface; occasionally we find 
them in more or less regular groups, whilst in other instances they 
are scattered unequally over various portions of the body. Some- 
times they are small as a pea, circular, shining, and of a decided 
coppery color, or, on the other hand, they are broad, flat, or spher- 
ical, round, or of an oval form. But, in the latter case, there are 
several mucous tubercles, such as I have described at the close of 
the first chapter. Sometimes the tubercles appear as if encased in 
the thickness of the tissues, or, again, as if protruding to a trifling 
extent. Under certain circumstances they remain smooth and 
shining ; in others, they are covered with light scales. Sometimes 
they become ulcerated and covered with thick crusts. In some 
patients the only trace they leave behind is a grayish spot, which 
at length disappears ; in others, they are replaced by an indelible 
cicatrix, which is more or less irregular, according to the existence 
or non-existence of previous ulceration. Sometimes the syphilitic 
tubercle, no matter what its gravity, passes through all its stages, 
and commits all its ravages from without inwards over every point 
where it is at first established ; sometimes, starting from a distant 
point it invades very extensive surfaces, destroying the skin more 
or less profoundly during its course. 

These tubercles are found at every point of the surface, and even 
on certain mucous membranes. But by a very unfortunate prefer- 
ence, they attack especially the face ; we find them then on the 
forehead, cheeks, and around the nose. Sometimes they appear 
in very small numbers ; at other times they break out suddenly 
and simultaneously wherever they are going to appear. In some 
patients their eruption is preceded by the syphilitic fever, of which 
I have spoken. Locally, there may be a certain reaction, a slight 
pain, a congestion of the surrounding skin, or, on the other hand, 
no change of this portion of the integument. According to M. 
Cazenave we may always detect some accidental exciting cause. 

Tubercles in Groups. — When tubercles exist in groups they are 
generally of small size ; they have but little tendency to ulceration; 
and their coppery hue is always well marked. Sometimes these 
groups are regular, more or less numerous, and perfectly circular ; 
the tubercles are of the size of a pea, prominent, very round, one 
by the side of another, forming a circle ; every patch, including 
both the tubercles and the interspaces by which they are separated, 
is of a coppery-red color. Each tubercle, besides, is often covered 
by small, hard, grayish scales, which do not completely cover 
their summit. Generally they do not terminate in ulceration ; their 
progress is slow ; they do not ordinarily produce either a stinging 
or an itching sensation. At length they subside, and resolution, 
though tardy, is generally complete ; no cicatrix remains. These 
groups of tubercles are found chiefly on the superior extremities, 
sometimes on the forehead and neck. Occasionally, on the other 
hand, the tubercles are grouped without any kind of order or regu- 
larity, as is represented in plate 6, fig. 4. Then they are generally 
small; but their form is more globular and circular, they are 
much more easily detached from the surface of the skin, as their 



SYPHILITIC ERUPTIONS. 367 

base is mucli less broad. They are, besides, of a shining color, 
and their coppery redness much more distinct. Sometimes, espe- 
cially on the face, this redness extends much beyond the surfaces 
which are the seat of the tubercles; in this case they are also 
accompanied with a slight tumefaction. This is certainly the form 
of syphilitic in which the real coppery color is the most decided. 
On pressing these tubercles with the fingers, we feel a resistance 
like that presented by large pin heads. They seldom become 
ulcerated; it sometimes happens, however, that after having re- 
mained a long time stationary they inflame, the groups coalesce, 
and on the excessively tumefied surfaces deep ulcerations are 
established. What is much more common, is to see these tuber- 
cles, after having been for a long time stationary, diminish in size 
and lose their color ; the redness becomes less and less marked, 
and resolution, after various lengths of time, is so complete that 
no trace of the tumor remains. This is the form most commonly 
observed on the face, especially on the cheeks and lips. 

Disseminated Syphilitic Tubercular Eruption. — This form appears 
particularly on the face; occasionally it is observed with the 
grouped variety, but it is then in the regular groups, those which 
form circles. Sometimes there are wide intervals between the 
tubercles ; the skin in the interstices is then faded, and of a dull 
color. They are at first small, but afterwards become larger than 
the others. Their -form is most generally irregular, but their base 
is broad. They have a decided copper color ; the skin covering 
them seems tense and shining. They rarely ulcerate, and secrete 
no matter. They are slow, both in their development and pro- 
gress. At first, as already stated, they are small ; they increase in 
size, and attain the volume of an olive. Then they become sta- 
tionary, and may remain so for a long time. A change afterwards 
occurs, they gradually diminish in size, become flattened, and dis- 
appear after two or three weeks, leaving only a spot which may 
remain for a month. Or, it may leave a smooth, superficial cica- 
trix, which has not been preceded by suppuration, ulceration, or 
any solution of continuity. In rare cases, the tubercles ulcerate, 
and then the cicatrix is more profound and irregular. 

Perforating Syphilitic Tubercular Eruption. — The name of this va- 
riety indicates its gravity. The tubercles are of large size, few in 
number, semi-spherical, and elevated at the summit, and have a 
broad base, which seems to penetrate the dermis, and to be con- 
founded with it. Individuals with a delicate soft skin present the 
greatest number of examples of this variety. They occur almost 
always on the face, attacking the nose, lip, and sometimes the 
pavillion of the ear. Ulceration in these cases is the_ rule. The 
tubercles, indeed, after a certain period of indolence, inflame and 
ulcerate at their summit, in two different manners : 1st. They be- 
come softened, slightly painful, and a superficiaHoss of substance 
occurs; they resemble small purulent collections which have 
united and opened, on which moist and slightly- adherent crusts 
form, and when they fall, leave a cicatrix which does not exceed 
the area of the tubercle ; 2d. The tubercle becomes tense, redder, 



368 VIDAL ON VENEREAL DISEASES. 

painful, and is surrounded by an erythematous patch. Ulceration 
invades its summit, and penetrates speedily throughout its entire 
thickness ; a thick and more humid crust forms, which soon falls, 
leaving a deep, perpendicular ulcer ; another crust forms and falls 
again ; a new destruction takes place, which is repaired at the 
expense of a deep violet-colored cicatrix, often appearing as if cut 
out with a punch, and representing a quarter, or half a circle. 
This destruction involves a portion of the cartilage of the ear, or 
of the lips, and especially of the nose. When new tubercles are 
developed after the first, the ulcerations may become confounded, 
producing a hideous mutilation of the face. It is not uncommon, 
then, to see both alas of the nose destroped, and what remains of 
this organ is represented by a large red stump. In rarer cases, 
the tubercles unite, a considerable tumefaction takes place, and by 
an effort of the organism, or under the influence of rational treat- 
ment, the whole gradually disappear without ulceration or suppu- 
ration. But, unfortunately, this cure is often only temporary; 
from various causes the tubercles reappear, ulcerate, and the havoc 
above mentioned follows ; or, on the other hand, reparation be- 
comes complete without any previous ulceration. 

Serpiginous Syphilitic Tubercular Eruption. — The ulceration is here 
more superficial than in the preceding variety. Instead of de- 
stroying from without inwards, as in the last variety, that is, deeply, 
the serpiginous form skims over the surface, as it were, of the skin, 
but always invades new regions. The furrows have been seen to 
cut up almost the whole surface of the body. 

This variety of tubercular eruption is observed on all parts of 
the body, but more particularly on the trunk, face, and wherever 
hair abounds. The tubercles, scattered irregularly here and there, 
are few in number at first, and of a volume varying from that of a 
large pea to a walnut. They are smooth, shining, of a decided 
coppery tint, remain stationary for some time, after which ulcera- 
tion supervenes ; a black crust is formed which falls. If repara- 
tion is not complete beneath it, we find a superficial, grayish 
ulceration, which becomes again covered with a crust, but less 
black in color, and of a less compact consistence. 

The ulceration increases by the destruction of tubercles already 
existing, or by those which are developed in the situation of the 
first, or their vicinity. The tubercle always precedes the ulcera- 
tion, and seems to direct. It is when a new tubercle appears, and, 
as it were, prepares the ground of the ulceration, that we perceive 
that reparation at an opposite point has commenced. At the same 
time we may observe, over a limited extent, 1st, the tubercles 
which prepare the ulceration ; 2d, the grayish ulceration, with 
perpendicular edges ; 3d, the points covered with crusts ; 4th, 
other points, the seat of the recently -formed cicatrix. 

These ulcerations generally leave very irregular, violet- colored 
cicatrices, perforated by numerous small vessels, and there are 
bridles, resembling those resulting from burns of the third degree. 
Sometimes nearly the whole surface of the patient's body is cov- 
ered with these cicatrices^ which occasionally degenerate, and as- 



SYPHILITIC ERUPTIONS. 369 

sume the characters of keloides. I have had under my care, in 
Ward 10, No. 26, a patient whose case was remarkable for the 
number and the aspect of these cicatrices. He was twenty -three 
years of age. He had ulcerations near the frenum, accompanied 
with a very abundant discharge between the glans and the pre- 
puce ; at the same time there was phimosis. These ulcerations 
lasted for about a year, alternately appearing and disappearing ; 
they were dressed with aromatic wine and Groulard's extract, a 
treatment which had been recommended at the Hopital du Midi. 
There was no bubo^ nor was there any eruption on the skin. 

One year after these ulcerations were cured, he had an attack of 
pharyngeal angina, and was treated by a homeopathist, who admin- 
istered globules to him for eight months. Two months afterwards, 
that is two years ago, he had an eruption on the skin. Accord- 
ing to the statement of the patient, this eruption commenced by a 
red pimple (tubercle) which appeared on the right leg. Similar 
pimples broke out on the right thigh, the hip, and the left nates, 
and on the posterior surface of the arm ; on the face, they occu- 
pied the chin, nose, forehead, and left mastoidean region. These 
pimples exhaled a fluid which formed into crusts. The patients 
remarked that these crusts were surrounded by a red circle, which, 
as it were, marched before them. The affection, in fact, did not 
remain stationary ; it extended from point to point, disappearing 
where first developed, to reappear on the adjacent parts ; so that, 
the cure preceding, or rather accompanying the ulceration, the lat- 
ter never occupied at the same time a space of a larger diameter 
than a half-eagle piece. At the points where the crust had disap- 
peared, a cicatrix formed, resembling that of a burn of the second 
degree. This form of cicatrization was not at every point the 
same ; in some regions — on the chin, nape of the neck, and fore- 
head — the patient observed fleshy growths, which attained a large 
size. One of them, situated on the forehead, and of the size of a wal- 
nut, was removed by a physician of Nantes, who prescribed a su- 
dorific syrup and two hundred pills of the proto-iodide of mercury. 
Under this treatment the ulcerations were speedily cured ; even the 
fleshy tumors, developed on the scars on the face, seemed to di- 
minish in volume. At present, May 15th, 1851, about three years 
since the appearance of the first eruption, the patient has neither 
tubercles, crusts, nor ulcerations. Instead of these, we find cica- 
trices of the character described ; on the legs, thighs, and arms, 
are broad cicatrices of a reddish color, irregular edges, covered by 
a thin transparent pellicle, and appearing to be consecutive to the 
ulcerations of the deeper layers of the dermis. On the face, the 
cicatrices, at points, are of a dull whitish color, at others they 
are of a bright or violet red color, but at certain points we 
observe something very remarkable, as, for example, on the cica- 
trices covering the chin and surrounding the mouth, perpendi- 
cular to the long diameter of the latter, we observe a kind of 
fleshy crest, about one and a half inches in length, not very thick, 
and about a line in height. This crest is of a reddish color, and 
covered with a thin pellicle, and strongly resembles the bridles re- 

24 



370 VIDAL ON VENEREAL DISEASES. 

suiting from burns. In the left mastoid region is a growth similar 
to that on the chin, but of much larger size ; it appears to be pro- 
duced by a swelling of the subcutaneous cellular tissue, but is ex- 
posed by the ulceration of the dermis ; it is of a red color, of an 
irregular form, and projects to the extent of some two lines, and is 
two inches in diameter, covered with a well-organized pellicle, the 
aspect of which resembles that of mucous membranes exposed to 
the air. Around this fleshy growth is seen a whitish cicatrix, on 
which this fungous growth is developed. The patient complained 
of no pain in these vicious cicatrices, in which he felt occasionally 
only an itching sensation. There were no other syphilitic accidents.* 

III.— CAUSES. 

In treating in general of the consecutive affections, I was com- 
pelled to speak of the causes of the syphilitic eruptions, since they 
are the accidents of most frequent occurrence. But, connected with 
these cutaneous eruptions, questions have been raised which I can- 
not pass in silence. It has been asked if blennorrhagia may be 
followed by a syphilitic eruption. Upon this point, in my opin- 
ion, there can be no question, since I have proved that there is a 
syphilitic blennorrhagia. These blennorrhagia, therefore, may 
produce the same effects as chancre. I do not believe that one of 
the forms of primary syphilis produces a more intense and speedy 
action on the system, and has a stronger tendency to cause erup- 
tions on the skin than another. Blennorrhagia, like chancre, may 
produce the syphilitic diathesis ; and the manifestations of this 
diathesis depend, not upon the cause, since in both it is identical, 
but upon other circumstances, and other influences. From what I 
have stated, my opinion may be inferred on the question, if there 
exist any real connection between certain primitive forms of syphi- 
lis and certain varieties of the eruptions : in other words, is Car- 
michael's doctrine true ? To this, I reply in the negative. I do 
not believe with the Irish surgeon, that blennorrhagia, or what we 
designate as simple chancre, must necessarily produce the papular 
eruption ; that the chancre with elevated edges {ulcus elevatum) is 
followed by the pustules; and that psoriasis depends upon the 
true Hunterian chancre : I do not believe in these imaginary de- 
pendencies, because I have seen the same chancre, the indurated 
chancre, followed by every variety of eruption ; and I have ob- 
served these same eruptions occurring as primary affections 
(d'emblee), in other words, without any preceding syphilitic acci- 
dent, without a blennorrhagia, or chancre of any kind. 

[Mr. Liston regarded the scaly eruption as pathognomonic of the 
chancrous form of primary sore (the Hunterian chancre). Although 
Mr. Acton believes in the doctrine of a simple virus, in a note on 
page 285 (2d Am. ed.), he observes : " And here I must agree 
with Mr. Carmichael in his belief, that indurated sores will be fol- 
lowed generally by a peculiar form of secondary accidents. These 

* Reported by my former interne, M. Pellagot. 



SYPHILITIC ERUPTIONS. 371 

eruptions are usually found to be scaly, and attended with sequela, 
which seems to have a strict relation to induration ; I believe to 
that gentleman we must give the credit of having called public 
attention to this view of the subject, which subsequent experience 
has confirmed." The true scaly eruption at the present day, like , 
the true Hunterian chancre, is rare, and, from what has come 
under our own observation, we are disposed to accept Mr. Car- 
michael's views — at least, so far as the scaly eruption is concerned. 
Doubtless, as suggested by Mr. Egan {pp. cit. p. 49), the desquamat- 
ing stage in which the majority of eruptions terminates, has led to 
confusion on this subject. — Gr. C. B.] 

The question is of more importance as regards the influence of 
treatment on the development of these eruptions, and especially 
the mercurial treatment. As soon as it became established that 
mercury is not indispensable to the reparation of a chancre, it was 
also pretended that this same agent did not prevent the appearance 
of the consecutive accidents, the syphilitic eruptions; finally, not 
only was its ritility contested, but dangers were attributed to its 
use, and it was accused of causing instead of preventing the erup- 
tion, whilst the more moderate maintained that the eruptions were 
less grave when mercury was not administered. 

It is very true, as has been already shown in this work, that 
chancre may heal without mercury, and that after the cure of this 
primitive accident no further trouble may be manifested. But 
this fact does not destroy that other fact, also unquestionable, of 
the greater frequency and gravity of the syphihtic eruptions when 
the primitive accident has not been treated ; that is, when there 
has been no specific treatment, and especially when mercury has 
not been employed. The utility of mercury, therefore, is evident ; 
it cannot be questioned by any true practitioner. The value of 
this agent, as a preventive of the syphilitic eruptions, and its 
efficacy as a curative means, is a sufficient reply to those who ac- 
cuse mercury of producing these affections. There is another ar- 
gument of still greater force ; it is based on the fact, that work- 
men, who are constantly exposed to mercurial emanations, and 
who suffer from salivation and mercurial tremors, are never affect- 
ed with venereal eruptions. Biett attached great importance to 
this fact in his Gliniqiies at the hospital St. Louis, where a large 
number of gilders came under his care. If to these workmen we 
add those who have never been exposed to the influences of mer- 
cury, and who have had chancres followed by the syphilitic erup- 
tions, we shall find that we have superabundant proof that the 
dangers of mercury have been exaggerated. To the primary 
cause, which is the syphilitic virus, and the other influences 
which we have mentioned, as concerned in the etiology of the 
syphilitic eruptions, we must add an occasional cause ; according 
to M. Cazenave, who always admits this element, whatever produces 
the simple,may prove the occasional cause of the syphilitic eruptions. 
This occasional cause may be a vapor bath, salt or fresh water 
bathing, excessive drinking, a violation of the laws of hygiene, or 
a strong mental emotion; a wound, an intermittent fever, the 



372 VIDAL ON VENEREAL DISEASES. 

application of a blister, intense cold, excessive fatigue a violent 
medicine, &c, may all likewise prove exciting causes. These can- 
not always be detected, but when they do exist may generally be 
appreciated. 

IV.— DIAGNOSIS. 

The diagnosis of the syphilitic eruptions is of great importance. 
A mistake here may be the cause of much domestic unhappiness, 
and lead to a specific treatment, which is not always free from in- 
conveniences ; on the other hand, a disease which unaided by art 
is seldom cured, may be abandoned to itself, and the traces of its 
ravages may be left in mutilations which might by proper treat- 
ment have been prevented. To avoid such errors, we must have 
recourse to the characters common to all the syphilitic eruptions, 
and to those peculiar to the individual varieties. I have entered 
into this double study at such lengths that I may here be brief. 
In cases of embarrassment, we must rely chiefly on the common 
characters, such as the color and form. The antecedents should 
be carefully investigated. But it should not be forgotten, that the 
first infection may have occurred in a manner unknown to the 
patient. A kiss, which a patient believed to be innocent, may be 
the cause of a frightful syphilitic eruption. The long interval 
between the appearance of the latter and the former act, may have 
caused it to be forgotten. A false pride may also induce the pa- 
tient to tell a falsehood, and there are certain conditions in private 
life into which the scrutiny of the physician cannot penetrate. 
Thus, for several reasons, we may fail in our efforts to obtain the 
antecedents of the case, which, however, affords us no excuse for 
discarding their value, or neglecting their search. To confirm or 
destroy the suspicions excited by a knowledge of the antecedents 
of the case, and to remove all doubts as to the character of the 
eruptions, a special treatment has been proposed, viz., the mer- 
curial. It is very true, that in the syphilitic eruptions mercury acts 
with power ; but its effects are not so certain and so prompt that 
we may avail ourselves of it in forming our diagnosis, for some 
cases of the nature of which there could be no question, have re- 
sisted every known mercurial preparation, and there are others 
which are modified by this agent only after a very protracted ad- 
ministration. Further still, there are eruptions not venereal, for 
the treatment of which mercury is of decided efficacy. It is be- 
sides improper to demand light from a source itself requiring it ; 
and it is certain that obscurity prevails as to the modus operandi 
of remedies. We must seek for an exact useful diagnosis in 
another quarter. We must carefully study the characters which 
distinguish these eruptions on their first appearance, with a view to 
their practical appreciation. First, we must endeavor to establish 
the special nature of the disease ; we must see whether it presents 
the common characters which render venereal affections so re- 
markable ; we must consult the syphilitic physiognomy. I think 
that I have sufficiently established these common characters. There 



SYPHILITIC ERUPTIONS. 373 

is a peculiar color belonging to the eruption itself, and a peculiar 
hue also of the sound parts, harmonizing with those which are 
diseased ; a disposition, a plan which seems to belong especially to 
them, and which, in connection with the other characters, con- 
stitute the basis of our diagnosis. If we thoroughly understand 
the characters common to all the syphilitic eruptions ; if we have 
several times observed them, they become so familiar, that at the 
first glance, and even at a distance, they may be recognized. 

[Mr. Erasmus Wilson, unquestionably a high authority in all 
matters pertaining to cutaneous pathology, thus speaks of the 
copper color, the pathognomonic character of the syphilitic erup- 
tions. After alluding to the different shades of this copper-color, 
according as it is blended with yellow, brown or red, he states 
that the reddish yellow brown is the true type of the color of the 
eruption under consideration. "The copper color represents, in 
fact, a declining stage of the eruption, when the congestion is sub- 
siding, and the yellow stain of the altered fluids of the skin shines 
through the purple of the blood. The ' copper color,' therefore, 
may have a greater or less amount of red or yellow in its com- 
position, and be either a reddish copper color, or a yellowish 
copper color." He remarks that the dull purplish red, the muddy 
red, and the yellowish red, called " copper colored," are by no 
means characteristic of the syphilitic eruptions, being commonly 
met with in chronic eruptions of other kinds, as, for example, 
acne. He has seen non-syphilitic eruptions possessing more of 
the dull and muddy hue, supposed to be peculiar to syphilis, than 
syphilitic eruptions themselves ; and " in selecting undoubted 
syphilitic eruptions in their earliest and best-developed stage for 
illustration in my 'Portraits of Diseases of the Skin,' I have some- 
times felt a regret that there was not more of the coppery hue 
present. But to have obtained 'this ' copper color,' I must have 
waited until the eruption was in its decline. The color of the 
skin must not, therefore, be relied on as proof of their syphilitic 
nature, although it may be fairly taken as a pathognomonic char- 
acter where other symptoms tending to the same diagnosis are 
found to be present." — Gr. C. BJ 

An early diagnosis is of the highest importance, for by it we 
arrive at a more accurate knowledge of the nature and special 
form of the eruption. These points being ascertained, we endeavor 
to determine to what order the eruption belongs. " Then it is," 
says M. Cazenave, " that we may advantageously apply the method 
of Willan ; then, also, should we scrupulously aim to avail our- 
selves of all the knowledge acquired by observation. Indeed, the 
diagnosis of the form is often attended with the greatest difficulties 
to be imagined ; and if it be remembered that the progress of 
venereal eruptions is essentially chronic, and that the elementary 
lesions, often not well marked, leave behind other lesions which 
may lead to confusion, we may see that for certain forms in par- 
ticular, these lesions are frequently of such a transient nature that 
they cannot be appreciated ; as, for example, in almost all the 
vesicular, and in the lenticular pustular eruptions. 



374 YIDAL ON VENEREAL DISEASES. 

The diagnosis, then, is chiefly based on a knowledge of the 
general characters ; it may, in many circumstances, be rendered 
more easy by other circumstances, which, however, are essen- 
tially connected with the eruptions themselves. Thus we may 
be greatly assisted by a knowledge of the accompanying symp- 
toms which are frequently observed, and by that of the pe- 
culiar characters which establish sufficiently the existence of 
the syphilitic affection, and which is especially manifested by a 
tendency to destruction. However, we should not attach more 
value to these otherwise important signs, than they really merit ; 
for, if ; as already stated, a syphilitic eruption may coexist with a 
simple eruption, still more may a special affection coexist with an 
extosis, &c. The concominant symptoms are then but a means of 
attaining a diagnosis, but on themselves they are insufficient to 
lead to a positive decision. On the other hand, other affections 
may leave behind cicatrices, and we should not be too readily in- 
clined to regard them as a proof of the action of syphilis, although 
the syphilitic cicatrix has an especial mark ; but the observations 
made in reference to accompanying symptoms apply to the cica- 
trices. In doubtful cases, assistance may be derived by appealing 
to the antecedents of the case ; but this can never be but an acces- 
sory means among others which shall conduct us to the discovery 
of the truth.* 

V.— PKOGNOSIS. 

The prognosis in the syphilitic eruptions is not generally of it- 
self grave ; the dangers arise from the complications and relapses, 
for in cases of relapse the skin is always affected to a greater 
depth. These affections, taken together, form two great groups. 
One, which is the most common, appears shortly after the primi- 
tive accidents, and assumes a character comparatively more acute, 
and extends over a large portion of the surface ; this group I call 
superficial, benign ; it consists principally of roseola, papules, and 
numerous superficial pustules. The other group is of a more 
chronic character, supervening upon the first when the latter has 
been badly treated ; in this group depth, instead of surface, is in- 
volved ; compared with the former, it is malign. The deep-seated 
pustules, the pustulo-crustaceous eruptions, those of chronic ecthy- 
ma, few in number but profound, which appear on the extremities 
and legs, and the tubercles which invade the face ; those which 
manifest themselves at a somewhat later period, before the osseous 
affections, or at a very late period, even after exostosis, are of a 
very grave character, because they exhaust the patient's strength, 
and leave indelible traces and sometimes mutilations which un- 
fortunately occur most frequently on the face, rendering the con- 
dition truly hideous. Add to these facts the difficulties in the 
way of treatment, much greater here than in the first category, 
and it will be evident that the deep-seated and chronic forms are 
of a more serious character than the superficial and acute. 

* Cazenave, Traite des syphilides, p. 554. 






SYPHILITIC ERUPTIONS. 375 

* 

The prognosis depends also upon the treatment. Now, as it has 
been shown that it is by the relapses that the syphilitic eruptions 
become more and more profound, we should endeavor to prevent 
them. The best means is a methodical treatment, into which mer- 
cury should almost always enter. It is true that the most judici- 
ous and best-directed treatment does not always prevent a return ; 
but, as it is also well established that these returns are much more 
frequent when the treatment has been improper and badly 
managed, the eruptions which occur at first should be thoroughly 
treated, or what is still better, the primary accidents should be ac- 
tively treated, so that eruptions may be prevented, or if they ap- 
pear, it shall be in a mild form, and one easy to be cured. 



VI.— TREATMENT. 

The treatment of the syphilitic eruptions is internal and external. 

INTERNAL TREATMENT. 

Having treated particularly of the internal treatment of the so- 
called consecutive venereal affections, and the syphilitic eruptions 
being among th*e most frequent of these, I shall here be brief. I 
must, however, repeat, to a certain extent, and add some details. 

It is evident that mercury should constitute the basis of our 
therapeutics. The form most frequently employed is the proto- 
iodide of mercury. In my opinion, mercury should never be dis- 
carded except when there is a very decided repulsion on the part 
of the system, and even then it should not be wholly thrown aside. 
I have seen, indeed, patients at first decidedly anti-pathic to mer- 
cury, and in whom it produced unpleasant effects in the abdomen 
and mouth ; some of these were debilitated by the smallest doses 
of mercury, and yet after having been strengthened by the pre- 
parations of iodine or iron, these same patients could take and 
tolerate the mercury, and it finally became the means of their cure. 
I have already mentioned these practical facts. I repeat, that I 
prefer to begin with small doses of mercury, for I fear that large 
doses will compel me to suspend the treatment, which would be an 
unfortunate circumstance, tending to favor the relapses and to 
make the subsequent treatment more difficult. However, I must 
acknowledge that I do sometimes discontinue the use of mercury 
even when it is well borne, but it is only when it has been used for 
a long time, as for two months, without arresting the progress of 
the disease. Then, if the patient retain his strength, I administer, 
every morning, a glass of Seidlitz water or of the citrate of mag- 
nesia, and after awhile resume the use of the mercury, which, in 
the majority of cases, then advantageously modifies the eruption, 
even in the same doses, which, before the repose, and the repeated 
purging, were ineffectual. When the constitution is much im- 
paired, instead of purging the patient, I resort to the preparations 
of iron, or the iodide of iron, or I confine my treatment to substan- 



376 VIDAL ON VENEREAL DISEASES. 

tial nourishment, with the view of always resuming the employ- 
ment of the mercury. 

The preparations of iodine, especially the iodide of potassium, 
should be administered when the eruption is deep-seated, and when 
it is complicated with other affections still more profound, a sub- 
cutaneous lesion, such as a periostosis or an exostosis. There are 
still many practitioners who conjoin with these means the use of 
sudorifics. Here, as in the treatment of the primitive accidents, a 
question arises which is difficult to decide, viz. that of the duration 
of the treatment. " In general," says M. Cazenave, " in the milder, 
recent forms, if the disease disappeared rapidly, in the course of a 
month or six weeks, for example, the treatment should be con- 
tinued for a month longer, dividing the time into three portions. 
One in which the complete treatment is maintained, and two 
others, in which the quantity administered is gradually reduced 
one-third. If the treatment has lasted for several months, the 
medicine should be discontinued for several days after the cure has 
been obtained, and then its employment should be resumed with 
the same decision as during the first several weeks." Thus, M. 
Cazenave recommences the treatment two or three times, according 
to the gravity of the preceding disease. In the severer forms, a 
still longer period is insisted upon ; and when after a long interval, 
the medicine having besides been well tolerated during the whole 
duration of the treatment, an intolerance is manifested, it is with 
the physician of the St. Louis hospital the strongest evidence that 
the disease is completely cured. 



EXTERNAL TREATMENT. 

The cure of the syphilitic eruptions may be promoted, their 
removal hastened, and certain local accidents mitigated by external 
means, by topical applications. Simple general bathing, starched 
or gelatinous baths, may prove of service in cases complicated with 
inflammation, and when there is a manifest over-excitement. In 
these cases, emollient, sedative, and even opiated fomentations 
may be advantageously employed. M. Cazenave condemns the 
use of cataplasms, which have been recommended by several prac- 
titioners, especially if applied for the purpose of promoting the 
separation of the crusts of certain syphilitic eruptions. By exposing 
the ulcerations they render them painful ; the ulers assume a bad 
aspect, enlarge and soon become covered with a new crust. It is 
much better for the crust to fall spontaneously, that is, that its 
separation should result from a rational treatment, which has pro- 
duced a reparation of the ulcer. When the eruptions are not 
irritable, baths, and simple vapor douches, may prove of service. 
The papular, tubercular, and squamous forms are speedily modified 
by these means. The cure of the syphilitic exanthemata, of lichen, 
of impetigo, is expedited by baths of amidon and gelatine. M. 
Cazenave has a high opinion of alkaline baths in the majority of 
the syphilitic pustular affections, especially when the dry crusts 



SYPHILITIC ERUPTIONS. 377 

seem to indicate that reparation is complete. He asserts that sifl- 
phurous baths are not in these cases particularly indicated. There 
are two kinds of baths still more special than those which have been 
mentioned ; these are the corrosive sublimate baths, and fumiga- 
tions with cinnabar. According to M. Cazenave, the sublimate 
baths are not to be trusted even as auxiliary means, in the treat- 
ment of the syphilitic eruptions. Considered as topical applications, 
these baths would be a rational means ; but they should not be 
confided in alone in our general treatment. The vapor baths of 
cinnabar are, on the contrary, generally approved. MM. Eicord 
and Cazenave agree on this point. The cinnabar fumigations may 
be either general or local. Ointments are but rarely employed. 
Those containing the proto-iodide of mercury are generally pre- 
ferred. M. Cazenave adopts the following formula : 

OINTMENT OF PROTO-IODIDE OF MERCURY. 

^. Hydrarg. Proto-iodide, grs. xv. 
Axung. J i. 

This is used in the dressing of the ulcerations of lupus syphilitica. 

In these same cases, if we desire to modify more actively the 
non-ulcerated tissues, we are to use the following, which is a true 
escharotic : 

OINTMENT OF THE * DEUT-IODLDE OF MERCURY. 

I£. Hydrarg. Deuto -iodide, gr. i. 
Axung. fi. 

M. Eicord states that he has found benefit in the squamous form 
from the use of the goudron ointment of M. Emery. This is 
the formula : 

GOUDRON OINTMENT. 

1^ . Pin. Sylvest, g iii. 
Axung. 3 x. 

Cauterizations are generally avoided. After the crusts in syph- 
ilitic rupia have separated, M. Eicord dresses the ulceration with 
charpie steeped in the following solution : 

SOLUTION OF IODINE. 

^ . Aq. dist. | vi. 
Tinct. Iod. J iss. 
Iod. Potass, grs. xv. 

The application of the sparadrap of Yigo cum mercuvia cannot be 
too highly recommended in the majority of the syphilitic eruptions. 
I have already mentioned an excellent example of the rapid cure 



378 VIDAL ON VENEREAL DISEASES. 

of several very grave, extensive, and serpiginous ulcerations. It 
is, perhaps, the means which most speedily removes the symptoms. 
The value of this plaster is most apparent in the treatment of cer- 
tain syphilitic eruptions on the face. 



SECTION II. 

DISEASES OF THE APPENDAGES OF THE SKIN. 
I— FALL OF THE EPIDERMIS. 

In the preceding section, when treating of the squamous syphil- 
itic eruptions, I alluded to an alteration of the epidermis which 
becomes of a horny nature on the soles of the feet and the palms 
of the hands. There are also certain other changes to which the 
epidermis is liable, and to which it is well here to refer. The 
epidermis, indeed, in all the consecutive accidents, becomes some- 
what thickened and discolored, of a white, grayish hue, and after- 
wards separates by little disks, and leaves the papillary substance 
covered only by a very thin layer of new epidermis. These phe- 
nomena are observed especially on the palms of the hands. Whc . 
these patches multiply and become united, the ejDidermis may 
separate to a very great extent : the 'fingers being in some cases 
likewise denuded. By some writers, this shedding of the epider- 
mis on the hands, feet, and other points of the body, has been 
called pelade. 

Occasionally the epidermis separates in extremely fine furfura- 
ceous desquamations, as, for example, on the scalp, thus producing 
alopecia, though, in some instances, there is no loss of the hair. 

II.— ALOPECIA. 

Those who have studied the different classifications of the acci- 
dents of syphilis, are aware that one of the first was made by 
Fernel. According to this eminent physician, the syphilitic virus 
does not invade at once the whole organism ; it penetrates by lay- 
ers, proceeding from the epidermis towards the deep-seated parts, 
until it reaches the bones. Adopting this theory, Fernel estab- 
lished four degrees of syphilis. In the first, the virus becomes 
insinuated like a vapor beneath the epidermis, producing a loss 
of the nails and hair. Fernel's theory, like all other theories, may 
be discarded, but the facts remain ; it is very true that alopecia is 
one of the first manifestations of the syphilitic infection. Here, 
however, we must carefully distinguish partial alopecia, from gen- 
eral, universal alopecia, involving the loss of the hair throughout 
the body. Without this distinction, it is impossible to explain the 
differences of opinion which exist in relation to alopecia, or to 



DISEASES OF THE APPENDAGES OF THE SKIN. 379 

commence a serious description of this accident. Thus it is evident 
that if M. Desruelles had recognized this distinction, he never 
could have asserted that this affection has almost entirely disap- 
peared,* that it is no longer observed ; and M. Lagneau would 
not have declared that it is exceedingly rare. If these authors 
intend their remarks to apply to general alopecia, then they are 
correct, but they would completely reject the facts, if they dis- 
puted the frequency of partial alopecia. This phenomenon, in- 
deed, is common in the commencement of the diathesis, when 
there are cephalalgia, and rheumatoid pains. M. Baumes, who 
agrees with me on this point, states "that this partial loss of the 
hair is observed after quite recent attacks of chancre and blennor- 
rhagia.^t In such cases there is sometimes a furfuraceous erup- 
tion, a slight desquamation of the epidermis at the roots of the 
hair, and alopecia occurs ; but this sometimes takes place without 
any apparent alteration of the epidermis. Friction, a slight trac- 
tion, the action of a comb, detach the hair on the scalp ; occasion- 
ally the hair on the body is removed in the same manner, but this 
is much more rare. 

In partial alopecia, the hairy bulbs are not always affected, or 
at least, they are not so much impaired as to prevent the growth 
of the hair. Such is not the case, however, with the hair on 
other parts of the body, proving that in persons thus affected, the 
infection is more complete. 

M. Reynaucl, of Toulon, has remarked that in partial alopecia, 
the affection assumes a circular form, and that this tendency which 
has been noticed in describing the general characters of the syph- 
ilitic eruptions, is manifested even here. The scalp is thus laid 
bare in disks, forming, as it were, little tonsures. The same thing 
may happen with the beard. Generally, we do not observe dur- 
ing the first stages of syphilitic infection this circular disposition 
in the falling of the hair ; but it is lost at various points ; some- 
times so slight is the loss, that it is not noticed. A little is brought 
away with the comb, and this is all that arrests the patient's atten- 
tion, and individuals who are negligent of their persons may be 
wholly unaware of the loss they sustain. It is owing to this cir- 
cumstance, that this phenomenon is rarely noted in the reports of 
cases, and that able writers have asserted that alopecia is very 
rare. 

General, universal alopecia is indeed rare, for it occurs only 
during the last stages of the diathesis, and frequently when a 
syphilitic cachexia has already formed. It is this degree of alo- 
pecia which, in the language of Brassavole, " gives to the patient 
a ridiculous aspect, for we cannot refrain from laughing when we 
see men without beards, without eyebrows and eyelashes.'^ I 
have seen an instance of complete, universal alopecia. The man 
was examined by several syphilographers, for he passed from the 
care of one to another. So completely was his system saturated 
with syphilis, that the whole habitude of his body was changed ; 

* Page 612. f T. ii., p. 411. \ JDe morbo gattico. 



380 VIDAL ON VENEREAL DISEASES. 

his virility was completely annulled; and so degraded was he, 
that his sex could hardly be recognized. Brassavole would have 
thought him more than ridiculous. He had lost all the hair on 
his head and body ; his eyebrows, beard, the hair on the pubes, 
and in the axilla, were all wanting. The complete report of the 
case has been published by M. de Castelneau in the Annates de la 
syphilis, tome i. 

Mercury is accused of producing alopecia, as it has been of all 
other consecutive accidents. M. Desruelles was the most decided 
on this point, and we know that other pupils of Broussais have 
repeated the accusation. No one acquainted with the dictates, or 
fruits, of a false system, will be surprised at this. There has been 
in fact, and still is, hyclrargyrophobia. But what is surprising, is, 
to see men who were never devoted to Broussais or his school, men 
of true merit, absolve syphilis and attribute the alopecia more or 
less directly to mercury. Of this number is M. Gribert. ( Vid. his 
Manuel, p. 433.) It may, however, be easily proved by two cir- 
cumstances that mercury has been unjustly accused, and that the 
syphilitic virus is the true cause. In the first place, observe the 
workmen who are daily subjected to the influence of mercurial 
emanations, and there observe what occurs in patients affected 
with syphilis, and who are never submitted to mercurial treatment. 
The former, the gilders, for example, have attacks of stomatitis, 
mercurial tremors, but never alopecia, except it be senile alopecia. 
Patients with the venereal disease, on the contrary, if the disease 
be left to itself, frequently have partial alopecia, at first, and if 
the disease continue to be neglected, and the diathesis reach a 
state of cachexy, the alopecia may become universal, and the pa- 
tients be deprived of all their hair. 

Alopecia, therefore, does actually occur ; it frequently presents 
itself under a mild and partial form, and is one of the first mani- 
festations of syphilitic infection. General alopecia is also some- 
times, though rarely observed, and in the last stages of the diath- 
esis. Both forms are independent of the effects of mercury. 
This agent, on the contrary, is one of the best means of prevent- 
ing or of arresting this accident. When it has become general, it 
is incurable, that is, there can be no hope of restoring the hair. 
"When, on the contrary, it is partial, and the diathesis has only 
commenced, a complete cure may be obtained. For this purpose 
a number of lotions and ointments have been invented, which, in 
my opinion, are useless. I repeat, that we must resort to the use 
of mercury. 

III.— ONYXIS. 

Under the influence of the syphilitic virus, the matrix of the 
nail sometimes suffers changes, which depend upon an inflamma- 
tion more or less acute. There is, also, often ulceration, but in 
many cases a vicious secretion only of the matrix is observed ; oc- 
casionally, but more rarely, the nail is lost without any appreci- 
able alteration of the skin. The ulcerative inflammation of the 



DISEASES OF THE APPENDAGES OF THE SKIN. SQ\ 

matrix of the nails is preceded bj a somewhat painful tumefaction 
around the nail, but especially around its root. The skin becomes 
alternately of a coppery and of a violet-red color. This part of 
the integuments, which at first become softened, is excavated by 
an ulceration which has a grayish, blenny base, covered by a san- 
ious liquid of a foetid and peculiar odor. At other times, on the 
contrary, the swelling which is round and folded on itself, projects 
on each side of the nail, and is separated from it by pus which may 
be made to issue on each side by pressing on the tumefied skin. This 
pus is often mixed with dark-colored blood. M. Cazenave states 
that he has frequently observed sleeplessness in these cases. It is 
rare that the skin does not at length ulcerate / in which case, the 
wound thus made more extensive, exposes a larger portion of the 
root of the nail. Whatever may be the progress of this inflam- 
mation, the pus which constantly bathes the matrix and the nail, 
completely detaches the latter, which in its fall, lays bare the ma- 
trix, which may not be ulcerated, when the nail will be quickly 
reproduced, however the disease may progress towards a cure. 
On the other hand, the matrix becomes ulcerated, and fungous, 
surrounded by a prominent swelling, itself ulcerated throughout 
nearly its whole extent, and then the nail is not reproduced ; the 
syphilitic ulceration is replaced by a furrowed cicatrix and small 
horny patches of no particular shape. This variety of onyxis, 
which was well described by Delpech, is rare; it attacks the 
fingers and the toes, but more frequently the fingers ; it forms one 
of the complications of the more or less severe symptoms of syphi- 
lis, and especially the syphilitic eruptions. 

The inflammation of the matrix of the nail does not generally 
advance in ulceration. The skin then remains intact. Sometimes 
there are very severe pains under the nail itself, but there is neither 
a tumefaction of the skin, nor purulent discharge. The secretion 
of the horny matter is vicious, and the nail may present a number 
of different alterations. 

"Sometimes it becomes at several points of a gray color, dry 
and broken at its free extremity ; sometimes, independently of 
these alterations, it becomes thickened for two-thirds of its extent, 
opaque, chaffed, and its exfoliated surface is reddish and unequal ; 
and what is remarkable, a well-marked line of demarkation sepa- 
rates the diseased from the sound parts, ordinarily represented by 
a surface beginning a little beyond its lunated portion where the 
nail preserves its luster, polish and its color. In some cases, how- 
ever, the alteration of the structure is general, and the nail is con- 
verted into a dry, grayish, chaffed, and very friable production. 
This form, well known to the ancients, is, I repeat, very common ; 
it is even rare for syphilis to exist for any length of time without 
involving, to a greater or less extent, the nails. It is always 
secondary. Sometimes it is the only symptom which reveals a 
consecutive syphilitic affection."* 

The following is an example of ulceration of the matrix of the 

* Cazenave, Traite des syphilides, p. 429. 



382 YIDAL ON VENEREAL DISEASES. 

nail; the last figure in plate 6 was taken from this subject. The 
patient, Teurtrier (Auguste) was twenty -three years of age ; a cook 
by profession, of a lymphatic temperament, and an impaired con- 
stitution. He was admitted on the 13 th Sept., 1851, into Ward 9, 
No. 13. 

Sept., 1850. Blennorrhagia which lasted five weeks, without 
complication. Cured entirely by copaiba. 

Oct. Bubo treated' by M. Puche, who has furnished information 
of the existence of, 1st, two indolent adenities ; 2d, an enlarged 
cervical ganglion on the left side. He left uncured on the 1st 
November, after having taken three ounces of the bromide of po- 
tassium. 

March, 1851. Blennorrhagia which lasted ten days ; there was 
a scanty muco-purulent discharge, which ceased completely under 
the influence of injections of Goulard's extract. 

June, 1851. Inguinal bubo on right side, painful, treated by 
antiphlogistics. At present, no ulceration on the glans or around 
the anus. Five weeks before the appearance of the bubo, patient 
suffered very intense peri-articular pains. 

July, 1851. Ulceration of the anus. From this time the patient 
commenced to take pills prescribed by a physician in town. This 
ulceration lasted four or five weeks ; at the time of its cicatrization 
(August), the right testicle very soon became inflamed, and pain- 
ful ; nevertheless, by the aid of a suspensory bandage he was able 
to work. The left testicle became in like manner speedily attacked. 
Towards the end of August, an exanthema-tons eruption appeared 
on both lower extremities. At the same time crusts formed at 
the roots of the hair, and the latter began to fall ; further, the 
ulcerations invaded the matrix of the nails of the middle and ring- 
finger of the right hand. Fifteen days afterwards, the patient pre- 
sented himself at the Hopital du Midi. There was no discharge, 
nor were there any traces of ulceration about the anus, which did 
not have an infundibuliform apjDearance. On the lower extremi- 
ties was an eruption of roseola, which at certain points had be- 
come converted into yellowish patches, and was undergoing a 
kind of desquamation. There were enlarged cervical and ingui- 
nal glands, but they were not painful. Both testicles were en- 
larged, and the epididymis was particularly the seat of the engorge- 
ment. The tunica albuginea was not hard to the touch. The right 
testicle was more engorged than the left ; both were nearly insensi- 
ble to pressure. The nail of the ring-finger was lost, and the whole 
matrix invaded by a grayish ulceration, secreting pus of an offen- 
sive odor. The nail of the middle finger was destroyed towards its 
root. The lunated form was destroyed and the nail distorted, as 
represented in plate 6. The patient had suffered at the ends of 
his fingers, but at the time of his admission these pains had ceased. 

19th. Was placed under the influence of iodide of potassium; 
forty-five grains in the day. 

25th. The induration of the right testicle has entirely disap- 
peared ; there remains only a very slight sensibility to pressure. 
The patient demands his discharge ; he would not finish his treat- 



AFFECTIONS OF THE MUCOUS MEMBRANES. 383 

ment at the hospital. In addition to the fact of the existence of a 
remarkable ulceration of the matrix of the nail, we here find both 
testicles affected with what is called syphilitic sarcoceles, and yet 
the epididymi alone were engorged ; even the substance of the 
testicle was intact, which is contrary to the opinion of those who 
pretend that syphilitic sarcocele affects exclusively the gland itself. 
The general treatment of onyxis is that of confirmed syphilis. 
However, as it is a symptom of deep infection, and as it is .often 
observed in feeble subjects, we should not insist too strongly on 
the use of mercury alone, but combine it with the iodide of potas- 
sium. It will have been remarked that the subject of the case just 
reported had taken the preparations of iodine only ; this was owing 
to the fact that he was feeble, and that the affection of the testicles 
was a proof of confirmed syphilis. It was my intention to add the 
proto-iodide of mercury when the patient regained his strength ; 
but, as has been stated, this patient would leave the hospital im- 
mediately after he began to improve. 

As to the local treatment, it must vary according to the more or 
less acute character of the onyxis, and according to the pains of 
which it may be the seat, and the period of the disease. 

Local emollient baths, to which laudanum may be added, cata- 
plasms of the same nature, should be preferred when the inflamma- 
tion assumes an acute character, and when the pains are severe. 
"When the inflammation has been subdued, the local treatment 
should be confined to dressings with calomel cerate, applied after 
washing the part with a dilute solution of chlorated water. 
Finally, in case of indolent fungous ulcerations, we should cauter- 
ize gently with the nitrate of silver three times in a day, and dress 
the part with the plaster of Vigo. 



SECTION III. 

AFFECTIONS OF THE MUCOUS MEMBRANES. 

The mucous membranes are too intimately connected with the 
skin not to participate in its diseases, especially when the essential 
cause of such diseases is a poison. We see, indeed, in all cuta- 
neous affections resulting from morbid poisons, the mucous mem- 
branes suffering to a greater or less extent ; and, generally, the 
manifestations are chiefly apparent in the throat, nose, and respira- 
tory passages. Thus, in scarlatina, there is a characteristic angina ; 
in rubeola, the lining membranes of the nose and larynx are 
affected, and every one knows that coryza is not rare in variola ; 
in miliaria, the lining membrane of the mouth becomes involved, 
as shown by apthse, and sometimes there is an eruption on the 
tongue which deprives it of its covering. 

In the syphilitic eruptions, we also find analogous affections of 
the mucous membrane of the throat, and especially that of the 



384 YIDAL ON VENEREAL DISEASES. 

month, and, it may be said, that in almost all the external, there 
are also internal syphilitic ernptions. Like the affections of the 
skin, those of the mncons membranes are often followed by ulcera- 
tions, and indeed snch a termination is more frequent in the latter 
than the former situation ; these solutions of continuity assume an 
elongated form, and constitute what are called rhagades. It is 
observed particularly at the anus, on the tongue, and the corner 
of the lips. The affections of the mucous membranes, moreover, 
afford the strongest evidence of constitutional syphilis, but, in 
general, they are not of a grave character, and speedily disappear 
under the mercurial treatment ; but these affections are also most 
readily and speedily reproduced, when this treatment is neither 
methodical nor complete. 

Modern writers on syphilis are not content to show the coinci 
dence of the cutaneous affections and those of the mucous mem 
branes ; some, as, for example, MM. Babington and Baumes, re 
cognize a repetition in the internal membranes of the forms oi 
eruptions described in the preceding section, when the syphilitic 
eruptions, properly so called, were discussed. 

In treating of the most important of these affections of the mu- 
cous membranes, we shall see whether such an opinion is perfectly 
correct. I shall commence with those of the membrane lining the 
buccal cavity, as this is the most frequent form of the internal 
eruption. 

I.— MUCOUS MEMBRANE OE THE MOUTH. 

M. Baumes establishes three forms of this affection : 
1st. The angina, corresponding to the syphilitic exanthemata, 
appears in patches more or less irregular, of a more or less lively 
red color, sometimes whitish at the centre, without tumefaction, or 
with a very slight tumefaction of the mucous membrane, occurring 
on the palatine arch, the velum palati, the pharynx, internal sur 
face of the lips, and cheeks. These patches are of short duration ; 
they disappear simultaneously with, or even before the cutaneous 
eruption. According to M. Baumes, if this form seems to be un- 
common, it is because the syphilitic exanthemata are themselves 
unfrequent, and because, being in themselves of no great import- 
ance, and producing but little inconvenience throughout their 
course, they escape attention. The last reason is the best ; as to 
the first, it does not accord with facts which prove that roseola is 
of very common occurrence. 

2d. The form of angina coinciding with the papular eruption 
consists, in the first place, of genuine mucous tubercles, that is, 
flat elevations, of a circular or oval form, but less prominent and 
less distinctly circumscribed than on the skin. Their surface has 
sometimes a slightly granular aspect. Their color is a little deeper 
than that of the surrounding mucous membrane ; they inflame but 
slightly, and are not more difficult to destroy than the mucous 
tubercles of the skin. In speaking in the first section of the 
mucous tubercles, I have mentioned these papules found at the 



AFFECTIONS OF THE MUCOUS MEMBRANES. 385 

commissure of the lips, within the lips and cheeks, on the velum 
and the pillars of the velum palati, and even towards the sides of 
the base of the tongue. Sometimes the papules assume the form 
of tubercles ; in that case they somewhat resemble the papillae on 
the base of the tongue, when the latter are morbidly developed, 
but, unlike the latter, they are not painful, nor are they seated on 
the edges and even on the point of the tongue. These elevations 
are sometimes wrinkled and elongated, and they speedily termi- 
nate by resolution, These little tumors do not ulcerate unless irri- 
tated by stimulants, or by rubbing against an adjoining, angular 
and cutting tooth. 

3d. The third form corresponds with the squamous variety, not 
in the presence of scales, the formation and sojourn of which on 
the surface of the lining membrane of the mouth are not possible, 
but in the disposition of the patches, the elevation, tumefaction, 
and redness of the mucous membrane, which, at one point, par- 
ticularly the central portion of these patches, presents the epider- 
mis raised, of a whitish color, wrinkled, and on its separation a 
very superficial, grayish ulceration. It is very probable, says M. 
Baumes, that if the epidermis, raised and constantly macerated by 
the fluids which fill the mouth, were not soon detached, a true, 
thin, and very extensive scale would be formed. This variety is 
met with on the palatine arch, the velum, the pillars of the fauces, 
the tonsils, the internal surface of the lips, and even of the tongue. 
This is of longer duration than the preceding variety. 

4th. According to M. Baumes, there is a pustular form corre- 
sponding to the pustular syphilitic eruption, but as the elevated 
epidermis is soon detached, as it is speedily destroyed, and is re- 
placed by ulceration, it becomes confounded with the following 
variety. 

5th. This fifth form should correspond to the ulcerated syphil- 
itic eruption. It is, according to M. Baumes, the most common, 
and that which gives rise to the most important considerations 
relative to its progress, duration, gravity, and the ravages it may 
commit in the mouth, and that, in fine, in which all the others 
terminate, when they become exasperated by any irritating cause. 
There must exist some varieties, but it is not always an easy mat- 
ter to distinguish them from ulcers produced by other causes. 
The very commencement of these superficial ulcerations, by a 
white or grayish surface, of which the circumference, without 
forming distinct edges, easy to be recognized as in the other ulcers, 
blends insensibly, as by a sort of levelling with the more depressed 
ulcerated part, occasionally presenting such an appearance as to 
produce the impression that no ulceration exists. 

The circumference of these ulcerations is ordinarily, for a greater 
or less distance, of a deep red color, which, contrasts with the dull 
white of the ulcerated surface. This surrounding redness is par- 
ticularly remarked when the ulcers are seated on the velum palati, 
the pillars of the velum, and the tumefied tonsils. It is often ab- 
sent in the ulcers on the lips, within the lips, and on the internal 
surface of the cheeks. Occasionally the whole bottom of the 

25 



386 VIDAL ON VENEREAL DISEASES. 

mouth, is lined with this kind of ulcerations, which is attended 
with a sensation of uneasiness and dryness rather than of pain, and 
does not interfere with deglutition unless deeply seated towards 
the base of the pillars of the velum palati. From the aspect and 
the irregular form of this affection, one might suppose that the 
parts had suffered from a burn of the first and second degree. 
According to the physician of Lyons, this is the kind of ulceration 
which forms the most important part of the constitutional symp- 
toms of blennorrhagia. 

In the second variety, the chancrous form is more strongly 
marked. The ulcer is superficial, though it involves the greater 
part or the whole of the thickness of the mucous membrane, has a 
grayish, granulated base, its edges are irregular, sometimes . de- 
tached, the circumference but little or not at all red colored, situ- 
ated on the tonsils, the pharynx, the pillars of the velum palati, 
the internal part of the lips and cheeks. Very frequently the parts 
adjacent to the dentes sapientias become invaded, or the points 
even through which these teeth protrude or are about to pro- 
trude ; we should guard against confounding the ulcers under 
consideration with those produced by the cutting of these teeth, 
at which time the mucous membrane is already disposed to in- 
flame and to become tumefied. In the normal state, this membrane 
ordinarily tolerates, without lesion, the pressure of teeth, or frag- 
ments of teeth, however irregular they may be ; but when it is 
irritated and inflamed, these teeth, or portions of teeth, wound it, 
and give rise to ulcerations, which, at first view, might not be 
readily distinguished from the venereal ulcers in question, even 
after inquiring into the antecedent or concomitant circumstances. 
The syphilitic ulcer is of long duration, is more obstinate, more 
difficult of cure than the preceding. It leaves a cicatrix on the 
mucous membrane, which continues for a long time, remaining 
smooth, whiter and more brilliant than the adjacent healthy mu- 
cous membrane. 

The third variety affects at first and almost exclusively, the ton- 
sils. The ulcer resembles a primary chancre, and without causing 
a previous tumefaction of the tonsils, " digs them out as it were 
with a punch;" it has a yellowish base, and a circumference of a 
deep red color, extending in every direction, sometimes the red- 
ness involves the whole surface of the tonsils and the surrounding 
parts, invading at times the orifices of the Eustachian tubes, and 
producing deafness or an alteration of hearing, much more fre- 
quently than the preceding ulceration. In some instances, this 
ulcer, in the first place, produces neither pain, inconvenience, nor 
impediment in deglutition; and if the patient's attention be at- 
tracted by either of the above circumstances, he is surprised to 
find that the ulcer has already made considerable progress. The 
latter is generally chronic, and attended with but little gene- 
ral disturbance. Occasionally, however, the inflammation is se- 
vere. 

In the fourth variety, the progress of the ulcer in its incipient 
state, resembles in part that of a phagedenic ulcer, with or without 



nt 



AFFECTIONS OF THE MUCOUS MEMBRANES. 387 

superficial gangrene. It is particularly in this variety, that the 
■ulceration is preceded and accompanied by pains which are some- 
times very severe, with febrile reaction, a difficulty or impossibility 
of swallowing, a change of voice, as well as of hearing, resulting 
from the extension of the ulcer to the uvula, the base and posterior 
part of the velum palati, the posterior and superior surface of the 
pharynx, the posterior and even superior part of the velum palati, 
bordering on the nasal fossse. These, together with the tonsils, 
are indeed the parts which are the most common seat of these ul- 
cerations. They are, however, likewise observed on the internal 
surface of the lips, and the inner and posterior surfaces of the 
cheeks. The progress of the phagedenic inflammation is some- 
times so rapid that the osseous tissues of the palate, behind the 
pharynx, and the nasal fossa?, become involved, in which case mat- 
ters assume a more serious character. The progress of the ulcer- 
ation is generally more rapid than in the preceding variety. 

It is probable that the different forms described by M. Baumes* 
correspond to the cases which he has observed. But I am of the 
opinion, that both in a theoretical and practical view of the sub- 
ject, we must here invoke the aid of synthesis. I shall therefore 
reduce to two varieties, the different forms of ulcerations in the 
buccal cavity ; 1st, the superficial variety, which is sometimes lim- 
ited to a slight erosion, and which, in the majority of cases, does 
not extend beyond the mucous membrane ; it is that which accom- 
panies the syphilitic eruptions, and which, in its course more or 
less resembles them ; 2d, the other, deep-seated ; destroying the 
mucous membrane as well as the parts beneath, and the affection 
does not generally commence in the mucous but cellular tissue be- 
neath, as in the case of syphilitic tubercles, and it may also com- 
mence in parts still more deeply seated. This form of ulceration 
may be observed in the absence of the eruptions, frequently after 
the cutaneous affection has disappeared, and even in the last stages 
of syphilis. It is ordinarily preceded by a tumefaction, partly in- 
flammatory and partly oedematous, of the parts about to be affected, 
which tumefaction impedes both deglutition and phonation. 
Sometimes an ulceration, the most profound, which destroys the 
uvula, the velum palati, or a tonsil, becomes known to the patient 
only by the functional lesions produced, which are often very 
slight, the patient in this case reposes in the most perfect secu- 
rity. But soon the mucous membrane becomes destroyed to a 
greater or less extent, and then an ulcer with perpendicular edges 
appears, its edges are more or less serrated, and it is surrounded 
by a red, oedematous tumefaction, whilst its base is covered by a 
grayish-yellow false membrane. Occasionally both the uvula and 
the velum are destroyed , the progress of the ulceration may be 
here very insidious, as it sometimes commences on the posterior 
surface of the velum. In other instances the posterior surface of 
the pharynx becomes attacked ; then, if the ulceration is not very 
extensive, and is central, we may observe its yellow base, and 

* Baumes, t. ii. 



338 YIDAL ON VENEREAL DISEASES. 

more or less tumefied borders. There are cases, however, in 
which we cannot define the limits, for the ulcer cannot be entirely 
exposed, neither by depressing the tongue, nor elevating the ve- 
lum to the utmost possible extent. When the ulceration is thus 
extensive, the tumefaction of the edges is considerable and involves 
the Eustachian tube, and produces deafness. Sometimes both ton- 
sils are affected with this deep-seated ulceration, but never to the 
same extent. Sometimes one only becomes excavated, the other 
remaining sound. This ulceration may be observed even on the 
tongue, either at its base or on its borders. A patient affected 
with these profound ulcers generally complains of suffering noc- 
turnal pains, and when the pharynx is their seat, there is difficulty 
of deglutition and phonation, with pain in moving the neck. 
Whatever may be the form of ulceration, its depth, or its connec- 
tion with other syphilitic accidents, the sub-maxillary glands may 
or may not become enlarged. 

There is a double motive for carefully studying this last form of 
ulceration ; in the first place, it sometimes progresses with great 
rapidity, and may thus commit the worst ravages in a short time, 
and in the second place, because treatment is here most triumph- 
ant; indeed, the iodide of potassium, administered in season and 
in large doses, will sometimes cause these ulcers to disappear as if 
by magic. 

Inoculation of a Consecutive Ulceration of the Tonsil. — Dr. L. wish- 
ing to ascertain if the pus of a secondary accident under the form 
of an ulcer could produce a syphilitic accident, performed an ex- 
periment in my amphitheatre, which I have reported to the Societe 
de Chirurgie. I insert in this place an extract from a report made 
by M. Begin, in the name of a Commission, of which M. Eicord 
formed a member. 

" For the purpose of giving a greater degree of certainty to a 
hygienic measure, proposed in the treatment of chancres of not 
more than ten days' duration, Dr. L. performed during the months 
of December and January, 1850-51, an inoculation with the pus 
of chancre, nearly every five days, which were made to cicatrize 
in four days by the application of cold-water lotions. 

" Three months after this first series of experiments, on the 2d 
of May, a friend of Dr. L. himself a physician, consulted the Dr. 
for an indurated chancre, contracted some seventeen days before, 
and which was seated in the groove at the base of the glands. 
After a little more than a month's duration, on the 17th May* the 
chancre was cicatrized ; the treatment is not mentioned. 

" Twenty -three days afterwards, a roseola, preceded by pains, 
appeared, and soon become complicated with an enlargement of 
the sub-maxillary glands, on both sides, and of the superficial and 
deep-seated glands on the right side. About the same time, that 
is on the seventh day after the appearance of the eruption, a pro- 
found ulceration was discovered on each tonsil, with fissures on the 

* I copy literally from the report published in the Bulletin de VAcademie 6a 
Medecine. 



AFFECTIONS OF THE MUCOUS MEMBRANES. 389 

tongue. This organ together with the whole buccal cavity was 
somewhat inflamed. These last-developed accidents were cured 
in thirty-four days after the first manifestation of the roseola. 

11 At this period, the twenty-second day of the existence of the 
chancres on the tonsils, (expression of M. Begin ; they were not 
chancres, for a chancre is a primitive, whilst this was a consecutive 
ulceration,) our experimenter resolved to inoculate himself with the 
matter which they furnished. With this view, two hours after he 
had carefully cleaned the surface of the left tonsil, he collected the 
serous, for it was hardly purulent fluid, which was secreted, and 
with a new lancet inserted it by a very superficial puncture on the 
anterior surface of the left arm. For the first ten days after the 
inoculation nothing in partiealar was observed, but on the eleventh, 
Dr. L. discovered a small pimple of the size of a pin's head, of a 
red color, and remarkable hardness, without an areola, and it was 
not painful even when pressed with considerable force. Towards 
the fifteenth day, this pimple, which had gradully increased in size 
until it had attained that of a lentil, became covered with crusts, 
which were united into one, and beneath it existed a reddish serous 
fluid. The latter furnished the matter used for the inoculation, 
four of which were repeated every fifth day, for twenty days, some 
twenty successive inoculations having in all been made."* 

It will be seen, even according to the report of M. Begin, that 
Dr. L. did really succeed in inoculating a secondary ulceration of 
the tonsil. His friend had had, in fact, a previous chancre, roseola, 
and afterwards ulcerations of the tonsils. Add to this, that the 
ulceration resulting from the experiment, occurred after a period 
of incubation. M. Chausit, who published the details of this ex- 
periment in the Annates des maladies de la peau et de la syphilis, 
observes: "This case, important when regarded in view of the 
object for which it was undertaken, and of the results already 
mentioned, presents, it must be acknowledged, great scientific 
interest ; when regarded in reference to syphilization it may shed 
a sad but strong light on this newly- developed principle. f M. 
Yidal (de Cassis) has fully presented this case in all its bearings. 
The important case, therefore, which is now furnished to science is 
at the same time a new proof of the inoculability of secondary 
syphilitic accidents, and in connection with this subject Ave must 
also notice another very important fact already placed beyond 
question by those furnished by Wallace and Waller, viz. the 
period of incubation intervening between the date of the inocula- 
tion and the time when the first specific accidents were manifested. 

* The report goes on to expose the experiments in syphilization. It was read 
on the 21st of January, 1852. 

f M. Chausit here alludes to the exasperation of the eruption, and the aspect of 
the chancres, as well as the increased number with which Dr. L. was affected, for 
the Dr. was presented to the Surgical Society and to the Academy as a victim of 
syphilization. It was for the purpose of completing the report of the case, and of 
turning it to a useful account, that I furnished the Surgical Society with the details 
relative to the inoculation of the secondary accidents. M. Velpeau did the same 
to the Academy, and a committee was appointed to examine the matter both in 
reference to syphilization and the transmissibility of secondary accidents. 



390 VIDAL ON VENEREAL DISEASES. 

" The different inoculations which Dr. L. afterwards made, seem 
to establish, contrary to the doctrine of M. Auzias, and to the 
experiments of M. Sperine, that the liability to syphilitic infection 
does not diminish in proportion to the number of inoculations 
performed, and that these inoculations may not contribute to ar- 
rest the progress of the pre-existing consecutive symptoms : this 
is an important fact, the value of which can be appreciated by our 
readers. As to the question proposed by M. Tidal (de Cassis), 
we know with what kind of a response it will meet at the onset, 
but there is an important matter here to be taken into considera- 
tion, for it is connected with the character even of the subject of 
this melancholy case. The experimenter was a physician, and 
the friend who voluntarily submitted to this series of experiments, 
was likewise a physician, circumstances which do not permit the 
intervention of such suppositions as are usually urged against 
facts of the kind we have mentioned." 

The hypothesis of a chancre has, in fact, been here reproduced, 
but, it must be confessed, with still less success than under other 
circumstances. The existence of this chancre could not be be- 
lieved, because, in the first place, a primitive chancre in this situa- 
tion has never been, and probably never will be, demonstrated. 
In the case in question, the subject of the experiments was him- 
self a physician, who observed for himself, and who is certain that 
the virus of a chancre never entered his mouth. He contracted a 
chancre on the penis, and it was after the cicatrization of this 
chancre, that he had constitutional syphilis, of which the tonsillar 
ulceration was an evidence. The existence of an enlarged sub- 
maxillary gland has been invoked, as indicating that of a chancre. 
But this gland was enlarged previous to the appearance of the 
ulcerations in the buccal cavity, and there were others on the 
posterior part of the neck. Glandular enlargement, I repeat, and 
will ever repeat, is of no value in the diagnosis of syphilitic ulcer- 
ations in general, for it may exist in scrofulous subjects, and may 
coincide both with the primitive and consecutive ulcerations ; it 
may doubtless exist in constitutional syphilis, yet the system may 
be completely infected, and yet the subject of this infection may 
be perfectly free from glandular enlargement in the neck or other 
regions. At present, there are in my service at the Hopital du 
Midi, two patients who are daily exhibited to the students : one 
of them, a coachman, has superficial ulcerations on both tonsils, 
which appeared shortly after the cicatrization of a chancre on the 
penis, and in this patient, the sub-maxillary glands are enlarged ; 
in the second, there are ulcerations on both tonsils, but they are 
more profound, and occurred at a later period ; in this patient, the | 
sub-maxillary glands are also enlarged. The chancre in the latter 
patient had existed for a year previously, and was situated on the 
penis. Both of these patients were questioned in every possible 
manner to ascertain whether direct infection could have occurred. 
In both cases, it was positively established that the ulcerations in 
the throat were consecutive. I retained these patients, and par- 
ticularly the coachman, a long time in the hospital. We may 



AFFECTIONS OF THE MUCOUS MEMBRANES. 391 

therefore, appreciate the value of glandular enlargements in the 
diagnosis of ulcerations. 

Treatment. — Here we must not forget the two principal varieties 
which I have established ; the one, superficial and peculiar to the 
first stages of constitutional syphilis ; the other profound, and cor- 
responding particularly to the last stages of the diathesis. 

1st. The first variety, consisting of superficial ulcerations, and 
co-existing with a syphilitic eruption, should be treated with the 
proto-iodide of mercury internally, according to the formula men- 
tioned while considering the treatment of the so-called consecutive 
venereal accidents. "We will here add another for a gargle to the 
parts : 

]J . Decoction of Oatmeal, § iii. 
Honey, 3 vi. 

Yan Swieten's Liquor, 3 iiss. 

2d. In the second variety, when the ulceration appears late, is 
deep-seated ; and occurs after the eruption, co-existing with the 
affections of the fibrous and osseous systems, we must employ the 
iodide of potassium, according to the formula described in treating 
of this therapeutic agent and its mode of administration. At page 
312, I have stated that I use one and a half ounces of the iodide 
of potassium to eight ounces of water, thus making fifteen grains 
of the iodide to a spoonful of this solution. Three spoonfuls may 
be given in the day ; seldom should the dose be increased to six 
spoonfuls. The gargle already mentioned may be employed, but 
instead of the two and a half drachms of Yan Swieten's liquor, we 
may substitute the same quantity of the iodide of potassium. M. 
Kicord frequently recommends the following gargle : 

3 . Aq. dist. § viss. 

Tinct. Iod. 3 iss. 
Iod. Potas. grs. xv. 

I have more than once observed that this gargle greatly irritates 
the throat. I therefore prefer that which does not contain the 
tincture of iodine, but the iodide of potassium in a somewhat con- 
siderable quantity. We should not always wait for the ulcerations 
in the buccal cavity to become profound before we resort to the 
iodide of potassium, both as an internal remedy and as a gargle. 
In order that the mucous membrane may not be destroyed, and 
the ulcerations become chronic, recourse must be had to this 
powerful agent, especially if the subject be debilitated. In such, 
mercury should be proscribed. In other cases, both of these 
agents may be united, and act conjointly, as I have already shown. 

In both varieties we may employ cauterization with hydro- 
chloric acid or the nitrate of silver. These means may be adopted 
in cases of mucous tubercles, especially when they cover a portion 
of the cheeks, the internal surface of the lips, and when there is 
not great inflammatory turgescence. When the ulcerations are 
profound, and of late development, and when they co-exist with 



392 VIDAL ON VENEREAL DISEASES. 

affections of the bones, the best remedy is still the iodide of pot- 
assium, both internally and in the form of a gargle, but in large 
doses. Cauterization may be attended with inconveniences during 
the first stages of the ulcerations ; it is better then to touch them 
with the following mixture, recommended by M. Baumes : 

$ . Mel. Ros. 3 ii. 

Laud, of Sydenham, v\. xv. 

"When the parts become less sensitive, and the edges of the ul- 
ceration less tumefied, less turgid, they may be touched with 

^. Mel. Ros. 3 ii. 

Hydro. Chlor. Acid. in., xv. a xx. 



II— MUCOUS MEMBRANE OF THE NOSE. 

Frequently after the cure of the primitive accidents, chancre and 
blennorrhagia, and when it is supposed that all is ended, the pa- 
tient experiences a kind of a stuffing, which, unless great care be 
taken, is regarded as a catarrh, but which lasts for a long time. 
He finds at length that his nose becomes more and more affected, 
and soon a thick yellowish purulent matter escapes, and oc- 
casionally with thin black crusts. The sense of smell becomes im- 
paired, and is lost, either on one or both sides. In many cases it 
is not until this period that the practitioner is consulted. He de- 
tects a redness with more or less fungous swelling of the mucous 
membrane of the nose, externally and internally, or on both sides 
at once extending to a greater or less height, so that it can no 
longer be perceived by the unassisted eye. Before this mucous 
membrane becomes ulcerated, that of the buccal cavity, together 
with the eruption, have preceded it. The affection of the nasal 
membrane is then regarded as a blennorrhagia, which existed 
previous to the ulcerations in the mouth. But at other times these 
ulcerations are speedily reproduced in the nostrils, within the alse 
of the nose ; or they may occur still higher, and penetrate more 
deeply to the surface of the inferior turbinated bones, so as to be 
difficult of detection. These ulcers may assume a phagedenic 
character, and destroy the different bones entering into the com- 
position of the nose and its cavities, which may become ulcerated 
simultaneously with the mucous membrane. 

The affection often commences in the bone ; the vertical layer 
of the ethmoid, and the turbinated, may suffer from necrosis or 
caries. When those belonging to the cartilages become attacked, 
the nose is depressed ; pressure on it produces a kind of crepita- 
tion ; portions of the bone issue with the mucus when the patient 
blows his nose. Then we have also those profound ulcers in the 
nasal fossse, which corrode the parts with or without caries of the 
bones, without much, or even with no suppuration, but with a 
fetid odor, a condition known under the name of ozoena. Ac- 



AFFECTIONS OF THE MUCOUS MEMBRANES. 393 

cording to M. Baumes, vegetations of a more or less fungous char- 
acter may form within the nose, under the influence of the syphi- 
litic diathesis, and more than one vesicular, spongy polypus, of a 
more or less vascular nature, may be due to this cause. This does 
not accord with my own experience. 

The consecutive inflammation of the nasal mucous membrane, 
often passes unnoticed, either because it ordinarily produces only 
an inconvenience and not pain, or because having an analogy to 
coryza, and because this annoyance about the nose may result 
from many other causes, the patient attaches but little importance 
to it. In this connection, these phenomena resemble certain others, 
such as a sensation of uneasiness, or of stiffness in the throat, a dis- 
charge from the auditory canal, with or without difficulty in hear- 
ing ; a slight smarting in the anus, symptoms which may be due, 
as in the first instance, to consecutive syphilitic ulcers in the 
throat, in the second, to a consecutive blennorrhagia of the mucous 
membrane of the auditory canal, and in the third, to a rliagade, 
and yet the patient who suffers but little, or not at all, and who 
apparently is in usual health, never attributes these symptoms to 
their true cause. But this same patient, one or two years after 
the cure of his primary accidents, consults his physician for symp- 
toms which are evidently constitutional. He then does not allude 
to the phenomena which had previously existed, because he is far 
from supposing that they were syphilitic, and these symptoms 
during perhaps a long interval of time, may alternately have in- 
creased, diminished, or have ceased entirely, and been replaced by 
other morbid phenomena on the part of the nervous system, or 
certain of the viscera. All these phenomena, however, are evi- 
dence of the long duration of the syphilitic diathesis, which has 
waited a favorable opportunity for a more terrible and manifest 
development. Examine carefully into the antecedent of the case, 
and you will find that these morbid affections, not very grave, yet 
truly syphilitic, previously existed and even yet exist, having 
suffered, in some manner, a transition by which the syphilitic symp- 
toms now apparent have been produced. These things I have 
often seen in my practice, and I doubt not that they have been 
observed by many other practitioners ; I have also remarked that, 
when an individual complains, some three, four, or five years after 
this cure of the primitive symptoms, of suffering, for the first time, 
from troubles which are unquestionably syphilitic, it is very rare 
that phenomena similar to the preceding have not existed, some- 
times constantly, at others being of an intermitted, irregular or 
periodical character, or occurring with the seasons, &c. I have 
never seen, for example, the syphilitic corroding dartre established 
on the alee of the nose by tubercles, unless there had previously 
existed, for a longer or shorter period, a chronic coryza more or 
less obstinate, and which was produced by the same syphilitic 
diathesis. 

It is evident here as well as in the buccal cavity, there are two 
stages, two varieties of ulceration : 1st, the more superficial, which 
precedes and afterwards accompanies the syphilitic eruptions, and 



394 TIDAL ON VENEREAL DISEASES. 

which, rarely involves the parts beneath the mucous membrane : 
2, that which occurs at a later period, which belongs to the last 
stages of syphilis, is profound, and always compromises the bones 
or the cartilages. 

In the treatment we must be governed by the rules already pre- 
scribed whilst treating of affections of the throat, that is, we should 
administer the proto-iodide of mercury in the first, and the iodide 
of potassium in the second variety. In the case of ozcena, we may 
inject the following solution into the nasal fossee. 

]£. Aq.dist., fx. 
Sod. Chlorid. 3 iiiss. 

[We have used injections of chloride of zinc, from three to six 
grains to the ounce of water, with the happiest effects. — Gr. C. B.] 



III.— MUCOUS MEMBKANE OF THE GENITAL ORGANS. 

Consecutive syphilis may affect the mucous membrane of the 
genital organs, in the same manner as in the primitive accidents. 
Thus consecutive urethral blennorrhagia has been observed, as 
has been balano -posthitis ; of this a case together with an illustration 
may be found in the first section of this word. In the female, 
whose genital mucous membrane is so extensive, we too frequently 
meet with discharges which are inordinately protracted in conse- 
quence of constitutional syphilis, the existence of which they per- 
sist in denying, and which, consequently, is not subjected to treat- 
ment. All the instances of consecutive blennorrhagia, are more 
or less chronic in their progress, and are attended with no marked 
excitement ; they are in fact more properly cases of blennorrhcea. 

They are not detected, or rather, their nature is not suspected 
until long after the occurrence of the primary symptoms, or when 
they accompany some other accident which is decidedly consecutive, 
as for example, a syphilitic eruption. And yet it is not unusual 
to attribute the discharge in both instances to a new contagion, 
and which besides may be they cause. Thus, we see, that the 
diagnosis of discharges resulting from constitutional syphilis is not 
easy, especially when we are unable to inspect directly the diseased 
mucous surface. When we have it in our power to examine it, 
we discover that it is not of a very bright redness, and that it has 
a tendency to assume the cojDpery color peculiar to the secondary 
affections. In plate 1 are two figures: one representing acute 
posthitis entirely primitive ; the other a consecutive and chronic 
balano-posthitis. The redness in the latter is browner and darker 
than in the preceding figure. The consecutive ulcerations of the 
genital mucous membrane are generally not so well defined as 
those which are primitive, like chancres, and reparation soon takes 
place, though the ulceration is speedily reproduced. These ulcer- 
ations occur on the prepuce, the internal surfaces of the labia, 
majora and minora. 



AFFECTIONS OF THE MUCOUS MEMBRANES. 395 

It is sometimes difficult to distinguish these consecutive ulcer- 
ations from that disposition to excoriations which the genital mu- 
cous membrane manifests when it has already been the seat of a 
primitive lesion which has lasted for any length of time ; thus, we 
frequently observe, after an indurated chancre on the prepuce, a 
disposition to a morbid excitement and ulceration of the mucous 
membrane, which is often mistaken for a consecutive affection ; 
the inflammation, ulceration, in these cases are liable to reappear, 
hence they are regarded as relapses. Most generally there is no- 
thing syphilitic in this condition of the preputial mucous mem- 
brane, and the patient is more easily cured by topical applications 
and simple measures, than by a mercurial treatment. The obser- 
vations apply to the ulcerations of the lining membrane of the 
vulva and of the whole genital apparatus in the female. 

[Granular erosion of the cervix nteri is stated by Dr. Bennet to 
be an exceedingly common lesion, in females suffering from the 
secondary forms of syphilis. He is inclined to believe that the 
proportion is as high as three out of four cases, in secondary syph- 
ilis (op. tit., 2d ed., pp. 326, 329). Dr. Egan's experience is op- 
posed to that of Mr. Bennet. " That this condition obtains in the 
most virtuous description of patients I cannot for a moment doubt, 
but that prostitutes enjoy a peculiar exemption from this formida- 
ble lesion I am perfectly satisfied. I have looked for it over and 
over again, both in individuals subject to discharges, and likewise 
in those affected with the secondary and tertiary form of syphilis ; 
and, with the exception of two instances, I most decidedly have never 
encountered ulcerations, properly so called, either of the exterior or in- 
terior of the uterus" (Egan, op. tit., pp. 131, 132). This view of 
the subject is supported by the evidence of Mr. Acton. " In 
women who suffer from syphilis in its worst forms, in all other 
parts of the body, the os uteri is very seldom affected, &c. ; these 
ulcers on the uterus are perfectly independent of syphilis in 
ninety-nine out of every hundred cases" (op. cit. p. 198). Gr. 0. B.] 

The judicious practitioner, therefore, will not be in haste to put 
his patient under the influence of mercury or of iodine, especially 
if the first has been administered for any considerable length of 
time and in a systematic manner. If, however, the ulceration of 
the mucous membranes co-exist with the syphilitic eruptions, or 
other concomitant lesions, of which the syphilitic nature cannot 
be questioned, the practitioner will then avail himself of these 
powerful agents. 

I should here speak of the vegetations and the mucous tubercles 
of the genital mucous membrane, but these have already been de- 
scribed in the first part of this work. The reader will recollect 
that I then insisted on the fact that these may be both primitive 
and consecutive. 

As to the general treatment, it is the same as that of the syphi- 
litic eruptions. The local treatment consists^ principally in isolat- 
ing the inflamed surfaces, and in the application of astringents. _ I 
consider that a weak solution of the nitrate of silver has astrin- 
gent properties. 



396 YIDAL 0]ST VENEREAL DISEASES. 

[We have frequently employed a solution of the sulphate of 
zinc, to which laudanum is added, with beneficial results The 
following formula answers a very good purpose : 

]J . Sulph. Zinc, 3 ss. 

Aq. pur. 3 vi. 

Tinct. Op. 3 ii. M. 
Apply as a lotion. G-. C. B.] 

The local treatment may exert a great influence in affections of 
the genital mucous membrane in the female. The observations 
which we have already made on intra-vaginal and intra-uterine in- 
jections, should here be reperused. 



IV.— MUCOUS MEMBRANE OF THE EPIGLOTTIS AND 

LARYNX. 

There are cases in which the affection of the fauces and the 
pharynx extend more deeply, and involve the epiglottis, producing 
serious impediment in deglutition. This disease, which is gen- 
erally in the form of ulceration, may affect the vocal apparatus, 
causing alterations of the voice much more decided, and variable, 
according as they involve the superior portion or whether they 
penetrate into the cavity of the larynx ; it may likewise occasion 
an oedema of the glottis.* 

When these ulcerations exist independently of an affection of 
the buccal cavity, it is often very difficult to detect their nature 
and to establish a differential diagnosis. According to M. Keynaud, 
who has carefully studied this form of syphilis, the laryngeal ul- 
ceration occurs only long after the primitive accidents. It may 
produce all the symptoms of ordinary diseases of the larynx, such 
as uneasiness, or a fixed pain on a level with the thyroid cartilage, 
and its extent may evidently in some cases increase the alterations 
of voice, the dyspnoea, the hacking cough and efforts made to ex- 
pel the mucosities which obstruct the glottis, after which the pa- 
tient expectorates a little purulent matter in some cases streaked 
with blood. The malady by becoming protracted may produce 
fever with night sweats, and all the train of symptoms of laryngeal 
phthisis. The firmer portions of the larynx sometimes participate 
in the disease and increase its gravity. Therefore, even in the 
more fortunate cases, in which we succeed in arresting the progress 
of the ulceration, and curing the disease, there generally remains 
aphonia, or at least profound alterations of the voice. The seat 
of the malady sufficiently indicates its gravity. 

[Mr. Carmichael, in his Clinical Lectures on Venereal Diseases, 
p. 143, refers to a case in which from extensive ulceration of the 
pharynx, the lingual artery gave way, and the patient died of 

* The reader may consult on this subject the Traite de Vangine laryngee (edema? 
teuse, of M. Sestier, p. 88. 



AFFECTIONS OF THE MUCOUS MEMBRANES. 397 

hemorrhage before assistance could be had to secure the vessel. 
He also exhibited preparations in his lecture, showing the neces- 
sity, in some cases, of resorting to tracheotomy in these distressing 
cases.— a. C. B.] 

The treament is similar to that of the consecutive affections of 
the buccal cavity ; but if the affection continues obstinate, remain- 
ing long after the subsidence of the tertiary symptoms, we must 
then resort to the use of iodine. In some cases even in spite of 
this remedy, the disease seems to continue, but it is then main- 
tained by a necrosis, the dead portion acting as a foreign substance, 
and though the syphilis be cured, the patient is far from being 
saved. 

V.— MUCOUS MEMBRANE OF THE EAR. 

The mucous, or rather the semi-mucous lining of the ear, may 
become affected by constitutional syphilis. In treating of mucous 
tubercles, I mentioned a case in which the patient's whole body 
was covered; they occupied both auditory canals; in one, was 
seen the raised papula, accompanied with a slight discharge ; in 
the other, there were ulceration of a dark brownish color, and a 
true otorrhoea. Hearing was not impaired. I have read, however, 
and we may find in the work of M. Baumes, that consecutive dis- 
charges from the ear coincide almost always with more or less dul- 
ness of hearing. True, the physician of Lyons intends his remarks 
to apply to greenish-yellow discharges. Those which I have ob- 
served consisted of a dirty, offensive serum. Cases have been de- 
scribed in which the ulcerations had the character of those belong- 
ing to constitutional syphilis ; they were seated both at the en- 
trance of the auditory canal, and at a greater depth, the latter 
being discovered only by the aid of the speculum auris. In such 
cases there is necessarily more or less of a discharge. According 
to M. Baumes, during the continuance of the discharge, soft, fung- 
ous, pediculated vegetations are to be seen in the auditory canal. I 
believe that these are most commonly mucous tubercles, at least 
such is the result of my own observation, and that the matter dis- 
charged proceeds from these tubercles. I have never seen any- 
thing in the ear that could be compared to true pediculated vege- 
tations. Of course, I do not include polypi in these remarks, as 
they have nothing in common with syphilis. 

When I have been called upon to treat mucous tubercles of the 
auditory canal, I have administered the proto-iodide of mercury 
internally, and have confined my topical applications to cleanli- 
ness. Lotions with diluted Goulard's extract, or with a dilute 
solution of the chlorides, and the insertion of cotton in the canals, 
may prove of service. 

VI.— MUCOUS MEMBRANE OF THE ANUS AND RECTUM. 

In speaking of blennorrhagia, in the first part of this work, I 
stated that anal discharges were most frequently the result of con- 



398 TIDAL ON VENEREAL DISEASES. 

secutive affections. These discharges generally proceed from con- 
secutive mucous tubercles ; but the most abundant source of the 
matter is particularly the mucous membrane surrounding these 
tubercles, which is the seat of a consecutive blennorrhagic inflam- 
mation. The vegetations, and especially the mucous membrane 
by which they are surrounded, may also secrete more or less mat- 
ter. These vegetations, in the great majority of cases, are consecu- 
tive affections. They may invade the mucous membrane to a 
much greater height than the mucous tubercles, which are always 
developed on the margin of the anus, and rather encroach on the 
nates, where they spread and multiply. On the contrary, the 
vegetations form high in the rectum, even on the lining membrane 
of this portion of the intestine, as may be seen by the speculum, 
or when the patient makes strong bearing-down efforts, as in going 
to stool. 

These ulcerations of the rectum, and particularly of the anus, 
are of frequent occurrence. In the majority of cases, they assume 
an elongated form, and are known by the name of rhagades. They 
have a grayish-yellow base, with edges more or less indurated and 
irregular. They may be seen completely when the patient forces 
down the parts, as in going to stool. They are much less painful 
both to the touch and during the act of defecation, than is the 
fissure of the anus, and we do not observe that disposition to syn- 
cope which is common to the latter affection. There is another 
kind of ulceration which is more superficial; it is observed in 
blennorrhagia, and is rather an excoriation, like that of balanitis. 
M. Baumes has met with greenish discharges from the anus, con- 
joined with other syphilitic symptoms. He examined with the 
speculum, and found the mucous membrane red and thickened, 
and as if granulated at certain points, without ulceration. But 
generally, with the puriform discharge there is ulceration, the lat- 
ter may occur without previous engorgement or induration of the 
mucous membrane. According to this writer, they may be found 
in large numbers very high in the rectum. 

The general treatment of the consecutive affections of the anus 
is that which has been recommended for the same morbid condi- 
tions in other mucous membranes. The local treatment consists 
particularly in the observance of cleanliness. Hip-baths should 
often be used. The anus should be filled with charpie or carded 
cotton. That portion of the mucous membrane which admits of 
being exposed, may be cauterized with the nitrate of silver. In- 
jections of Goulard's lotion, or a solution of the nitrate of silver, 
may be used when the affection extends to any great height. We 
should avoid injections containing laudanum. I have seen poison- 
ing produced which threatened the most deplorable consequences, 
by injecting a solution containing sulphate of zinc and a large 
proportion of Sydenhams's laudanum. 



DISEASES OF THE EYES. 399 

SECTION IV. 

DISEASES OF THE EYES. 

In the first part of this work, I have already described a serious 
affection of the eyes, which commences in the more external mem- 
brane, the conjunctiva ; it is one of the so-called primitive venereal 
accidents, a form of conjunctivitis. A consecutive conjunctivitis 
has been mentioned, or rather it has been supposed, for what has 
probably been regarded as a manifestation of secondary syphilis 
in the ocular mucous membrane, was probably a chronic conjunc- 
tivitis succeeding to a blennorrhagic ophthalmia, or it may have 
been the latter in a protracted state, or a conjunctivitis dependent 
on some other diathesis which cannot be determined. As to the 
lesions of the other tissues of the eye, they are still more problem- 
atical, or if they have indeed been observed, it was in severe cases 
of iritis with extension of the inflammation, or, more properly 
speaking, in complicated cases. Thus, writers speak of a complete 
disorganization of the globe of the eye resulting from syphilitic 
iritis. Mackenzie alludes to this accident, and I have now in my 
service, Ward 11, a patient who has passed through all the stages 
and demi-stages of syphilis : he has a sunken eye. It was not 
long after this profound lesion that we saw him, so that we were 
able to note the starting point of the ophthalmic affection. We 
obtained sufficient proof that he had not blennorrhagia at the time 
when the eye became affected, so that the eye was not in this case 
lost, as is observed in a severe case of blennorrhagic ophthalmia, 
but it was the result of a lesion occurring during the development 
of various consecutive accidents, or, probably, of an accident itself 
of this nature, but of a much more serious character than that 
which is most commonly observed, viz., syphilitic iritis. The iris 
is indeed most commonly affected when the virus has infected the 
whole organism ; and this lesion alone is noticed by some writers 
on venereal diseases. I will devote a paragraph to it. 

SYPHILITIC IRITIS. 

M. Eicord, in his Notes to Hunter, thus remarks: "There is a 
secondary accident to which Hunter has not alluded, because it 
escaped the laws which he had established, or what is very probable, 
because he was ignorant of the disease." I quote verbatim* 

Causes. — Syphilitic iritis is so intimately connected with the 
affections of the skin, it occurs so frequently in their train, that it 
may be regarded as one of the accidents of the syphilitic eruptions. 
It is for this reason that I treat of this disease immediately after 
the affections of the skin and mucous membranes. 

* Hunter, 2d Ed., Note by M. Ricord, p. 648. 



400 VIDAL Otf VEXEREAL DISEASES. 

Attempts have been made to determine what form of syphilitic 
eruption is more frequently followed by syphilitic iritis. Accord- 
ing to M. Legendre, it is the papular and the pustular varieties, 
{Thesis already quoted) Mackenzie states that his experience has 
shown that the pustular and squamous eruptions on the face and 
trunk should take the first rank, whilst the second should be 
assigned to the syphilitic affections of the throat. " The pustules 
on the face," says Mackenzie, " which I have observed to coincide 
with syphilitic iritis, were often voluminous, hard, and penetrated 
the skin so deeply that they almost deserved the name of tubercles. 
The squamous eruptions on the face sometimes resembled the 
areolar form of lepra. On the body, where the eruption had gene- 
rally a more acute character, it appeared under the form of numer- 
ous circular elevations, of a brownish-red color, about half the size 
of a pea, and terminating by a succession of thin pellicular desqua- 
mations of the epidermis."* 

M. Eicord admits three degrees of syphilitic iritis. According 
to this writer, if the patient is affected with the syphilitic exanthe- 
mata, rubeola, the iritis coincident with this form of eruption, with 
other things being equal, will be less intense, forming what is 
known under the name of erythematous iritis, and which some oph- 
thalmologists call serous iritis. There is another iritis accompany- 
ing the papular form of eruption ; in this variety, under certain 
circumstances, vegetations are observed, which Beer has compared 
to condylomatous vegetations ; but most frequently, says M. Eicord, 
we observe on the iris genuine papules, more or less prominent, of 
the size of a grain of millet seed, and of a copper-red color. 
Finally, when the iritis co-exists with a vesicular or a vesico-papu- 
lar eruption, we discover on the iris true vesicles, vesico-pustules, 
and we may even say, small ecthymatous pustules. Each principal 
form of cutaneous eruption should therefore have its prototype on 
the iris. Such is the opinion of M. Eicord. Thus we have not 
only a syphilitic iritis but several varieties corresponding to the 
several syphilitic eruptions. And yet M. Eicord concludes by 
doubting the existence of syphilitic iritis ; he seems to reject the 
disease, as a distinct variety, after having described three different 
forms ! In the same note, by the same syphilographer, we read 
as follows : "In the absence of all pathognomonic signs, we are j rati- 
fied in asking, as in certain cases of pemphigus in the infant, 
whether syphilis does not here act like any other common cause."f 
So that after all, syphilis in these cases acts like cold, or any other 
non-specific exciting cause ; and this, too, for the reason that this 
iritis has not a specific character by itself. As if the antecedents, 
the progress of the malady, its relations with other concomitant 
circumstances, such as the syphilitic eruptions, and the whole 
pathological history of iritis, were not equal to an anatomical 
character in establishing its nature ! 



* Mackenzie, Maladies des yeux, p. Zll, translated into French, by MM. Laugier 
and Richelot. 

f Vid. Notes to Hunter, p. 682, 2d ed. 



DISEASES OF THE EYES. 401 

[Among the writers who first described syphilitic iritis as a dis- 
tinct disease, were Prof. Schmidt, of Vienna, and Mr. Saunders, of 
London. Although the highest authorities of the present day, 
such as Messrs. Lawrence, Jones, Hilton, and Mackenzie, as did 
Mr. Carmichael, regard it as a specific affection of the iris, there are 
others, as observed by our author, who can see in it nothing to 
entitle it to such a distinction. Mr. Porter objects to the term 
iritis, believing, as he does, that all, or almost all the other struc- 
tures participate in the disease. "I have seen patients become 
blind long after every symptom of the ' iritis ' had disappeared, 
and I have witnessed the unpleasant situation in which a surgeon 
was placed, who had, under such circumstances, pronounced his 
patient cured. I prefer, therefore, that name which tells us and 
keeps constantly before us the fact, that all the deeper structures 
of the eye are engaged — deep-seated syphilitic ophthalmia," (Lect. 
in Dub. "Med. Press., April, 1847.) Mr. Morgan believed, and this 
is the doctrine, if we mistake not, of Mr. Travers, that the form of 
iritis under consideration is due to the conjoint agency of syphilis 
and mercury, but Mr. Lawrence has quoted a number of cases in 
which mercury had been given in some quantity, for the cure of 
the primary sore, in about one-third of the whole number ; very 
little, in about another third, and no mercury at all in the remain- 
ing third, and yet iritis supervened. Similar results followed 
the non-mercurial practice of Messrs. Eose and Thompson. — 
G. C. B.] 

Symptoms. — Diagnosis. — In the first place, I should remark, that 
iritis, whatever may be its cause and nature, may present the fol- 
lowing characters: 1st. A particular vascularity of the opaque 
cornea and even of the iris ; 2d. A modification in the motions 
and form of the pupils ; 3d. A production of lymph, of a more or 
less purulent fluid, and adhesions ; 4th. Impaired vision and pains 
in the eye and around the eye, and even beyond this region, but 
always confined to the head. Thus, we have what is called Zonu- 
lar sclerotitis, that is, very fine vessels, which run like rays towards 
the margin of the transparent cornea. The color of the iris is 
changed by an abnormal vascular development, or the production 
of lymph, in its substance, or on its posterior surface. If it is 
naturally blue it becomes green, and if of a red disk color it 
changes to brown. The pupil contracts and its motions are im- 
paired or destroyed. The lymph of which I have spoken may be 
effused in the posterior as well as the anterior chamber of the eye. 
This same lymph may become organized on certain portions of the 
membranes, forming bridles and producing adhesions of the margin 
of the pupil to the capsule of the crystalline lens, and sometimes, 
though more rarely, to the cornea. These morbid productions 
may assume the form of tubercles, or of pustules ; we then have, 
in the majority of cases, abscesses in the iris. Finally, there are 
subjective symptoms relating to vision, which is more or less dis- 
turbed and sometimes destroyed, and there are circumorbitar pains, 
which may be nocturnal. These characters are not observed in 

26 



402 VIDAL OX VEXEREAL DISEASES. 

all cases of iritis, but they may be met with, from whatever cause 
the disease may occur.* 

The Germans, at the head of whom stands Beer, describe among 
the characteristics of a specific iritis, a peculiar distortion of the 
pupil, and the development of what are called condyloma on the 
iris. The first is produced by a gradual contraction of the pupil 
from without inwards ; instead, therefore, of being in the centre of 
the iris, it is much nearer its superior internal border, thus causing 
a deformity, a laceration of the pupil, converting its grand axis 
obliquely from below upwards, and from without inwards. This 
distortion may certainly occur during the existence of syphilitic 
iritis, but it is also observed during that of rheumatic iritis. Fur- 
ther still, by following the different phases of syphilitic iritis, we 
may observe both this distortion and that in the opposite direction. 
This character, therefore, is governed by no law ; it may depend 
upon the adhesions to the crystalline lens and the effects of bella- 
donna so frequently employed in the treatment of iritis. If the 
adhesions no longer exist at the time when the belladonna is em- 
ployed, the pupil will dilate equally in all directions, presenting 
not the slightest deformity. If, however, adhesions still exist, the 
dilatation of the pupil will then be irregular, and then only do we 
perceive distortions of the pupil ; they result from the action of 
the belladonna, dilating the portions of the iris free from adhe- 
sions, whilst the position of those which are adherent remains un- 
changed ; thence the distortions, which are not constant, and con- 
sequently cannot be regarded as pathognomonic. M. Legendre 
has twice seen the contracted and circular pupils dilated by the 
action of belladonna, and assume an oblique form from below up- 
wards, and from within outwards, a direction the opposite of that 
which is regarded as pathognomonic ; in another case, the pupil 
was vertical and lozenge-shaped ; and, finally, in other instances, 
it could not be made to assume any particular figure. The distor- 
tion of the pupil, accidentally produced by the belladonna, is repro- 
duced, but in a permanent manner, by the cure of the iritis. Indeed, 
when the circular coarctation ceases on the disappearance of the 
disease, the pupil has a tendency to reume its natural shape ; but if, 
during its contraction, adhesions form, and the unadherent portions 
only should become dilated, a permanent distortion then results. 

As to the condylomata, according to some of the best ophthal- 
mologists, they are but abscesses which occur more frequently in 
syphilitic than in other forms of iritis. "We should therefore take 
into consideration the circumstances of their existence, especially 
if they co-exist with a syphilitic cutaneous eruption, as they will 
then be of more value in establishing our diagnosis. 

Mackenzie alludes to a rusty color of the iris near its pupillary 
margin : a phenomenon, he observes, which is sure to be met with 
in syphilitic iritis. But M. Desmarres has seen this color in cases 
of iritis, without any special complication. 

* Vid. in my Pathologie externe the different forms and degrees of Iritis, t. iii. p. 
18, et suiv, 3d ed. 



DISEASES OF THE EYES. 403 

The progress and the character of the pains in syphilitic iritis 
deserve the greatest attention. Its progress is slower and less acute 
than that of traumatic iritis, which very frequently terminates in 
the rapid and complete obliteration of the pupil. The cause of 
traumatic iritis being entirely local, its effects seem to be limited 
to the eye affected ; nothing, on the contrary, is more common 
than to see the other eye attacked in syphilitic iritis, and scarcely 
does the inflammation subside before it reappears, and so it pro- 
ceeds, until several relapses have occurred. It is frequently the 
case, that false membranes are not formed until after several 
attacks of inflammation in the same iris, and they rarely produce 
an obliteration of the pupil, even when the disease is abandoned 
to itself. Disorganizations of the eye, and staphylomas, very sel- 
dom result from this specific iritis. 

Pain in syphilitic iritis evidently occurs in paroxysms ; these 
paroxysms are nocturnal, and, if pain exists during the day, there 
is always an exacerbation at night. It seldom occurs before eleven 
o'clock at night, and most generally at midnight, or at one o'clock 
in the morning. These pains are seated not only in the globe of 
the eye and orbit, but the corresponding side of the head ; some- 
times it extends towards the occiput. I am perfectly aware that 
other forms of iritis are attended with nocturnal pains — as, for ex- 
ample, the rheumatic, and even simple iritis ; but I believe that 
this phenomenon is much more decided in syphilitic iritis. I attach 
much more importance to it than to condyloma, for these I have 
rarely observed, whilst the nocturnal pains have never been absent 
in cases of iritis where the disease has been at all severe. I should 
add, that the sulphate of quinine exerts a powerful influence over 
these pains ; the hour of the accession of the paroxysms may, 
therefore, be changed, and finally they may be entirely removed 
by this potent agent. 

None of the anatomical and physiological characters of iritis, 
taken separately, can be regarded as proof of its syphilitic nature. 
But, united, they possess a real value in forming a diagnosis, and 
this is especially true of those relating to its progress and the na- 
ture of the pains. First of all, the skin should be examined, if 
we would establish a sure diagnosis. I have already attempted 
to show the intimate connection existing between the syphilitic 
eruptions and iritis. It is such, that I consider the existence of 
syphilitic iritis impossible without the cutaneous eruption. Indeed, 
we shall find, almost invariably, some of these eruptions, or traces 
of them, and if not yet developed, it soon will be, before the iritis 
can have made much progress. In cases where the skin appears 
to be perfectly sound, we shall probably find on the mucous 
membranes in the buccal cavity, the anus and genital organs, le- 
sions analogous to the s} 7 philitic eruptions. Certainty of diagnosis, 
therefore, is established by taking into consideration circumstances 
unconnected with the symptomatology of iritis. But this is no 
reason why we should attach but slight importance to the elements 
which the symptomatology may furnish, for they may lead us to 



404 VIDAL OX VENEREAL DISEASES. 

an examination of the cutaneous surface, which might otherwise 
have been neglected. 

I shall not here attempt to establish the varieties of syphilitic 
iritis. I have already stated that M. *Ricord has assigned a form 
of iritis to each variety of the eruption. He recognizes an ery- 
thematous, a papular, and a pustular iritis. The mildest form 
should therefore correspond to the milder forms of the eruption, 
and vice versa. I will only remark, that I have observed very 
slight and perfectly erythematous forms of iritis, with the graver 
forms of the cutaneous eruption. Thus the subject of the squa- 
mous eruption represented in plate 5, fig. 3, was affected with the 
mildest form of iritis, which was cured in eight days, and yet the 
eruption on this patient was very obstinate ; the testicles became 
affected, his constitution deteriorated, and finally the constitutional 
infection was very complete. 

Prognosis. — The gravity of the prognosis does not depend upon 
that of the syphilitic iritis itself, for, like the inflammation of the 
iris, it is perhaps one of the least compromising as regards vision. 
One circumstance which should render the prognosis very guard- 
ed, is the evident tendency of this disease to return. But the 
danger arises principally from the changes produced in the sys- 
tem, by the establishment of the syphilitic diathesis. Indeed, the 
iritis almost always supervening on constitutional syphilis, and 
after other manifestations of the disease, the patient is generally 
debilitated, and consequently intolerant of antiphlogistic and other 
debilitating remedies which form the principal part in the thera- 
peutics of iritis. 

Treatment. — Blood-letting is frequently indicated. Monteath in- 
sists upon the absolute necessity of this measure, especially in par- 
ticular cases ; he opposed his experience to those who place all 
their confidence in the use of mercury, to the exclusion of all 
other means, such as blood-letting, blisters, &c. This practitioner 
has seen, indeed, syphilitic iritis running rapidly into a dangerous 
hypopion, notwithstanding mercury had produced its complete 
effect, and yet its progress was at once arrested by repeated vene- 
section in the arm, and the application of a blister to the nape of 
the neck. Mackenzie, who quotes and coincides with Monteath, 
states that he has been obliged several times to repeat venesection 
in the arm, besides resorting to the application of leeches, before 
he could affect the disease so as to derive advantages from the 
use of mercury.* 

Unfortunately, syphilitic iritis often occurs in subjects whose 
constitutions, greatly debilitated, will not tolerate the abstraction 
of blood. Applications are frequently made to parts adjacent to 
the orbit, and to the eyelids, for the purpose of mitigating the 
pains, and preventing contraction and obliteration of the pupil, 
and they are either of an antiphlogistic character, or have a ten- 
dency to overcome the diathesis. Opiated frictions are commonly 
used to relieve the nocturnal pains ; they should be applied about 

* Maladies des ycux, p. 3*78, French Translation. 






DISEASES OF THE EYES. 405 

an hour before the expected attack. The eye may afterwards be 
covered with a folded compress which has been previously warmed 
before a fire. "Whenever the paroxysms threaten to return, and 
this generally occurs about midnight, these frictions with opium 
should be renewed. Opiated mercurial ointment has also been 
employed, or the tincture of tobacco, according to the circum- 
stances of the case and the judgment of the practitioner. The ex- 
tract of belladonna, in the form of an ointment, is much used ac- 
cording to the following formula : 

]J. Ext. Belladon. grs. xv. 
Axung. | i. 

An application of a mixture of one part of extract of belladonna 
and one of mercurial ointment, is also employed ; but precautions 
should be taken when belladonna is used in large quantities. It 
is proper here to allude to a phenomenon which has often been 
observed, and which is noticed by M. Yelpeau. The extract of 
belladonna is generally employed for the purpose of preventing 
the contraction of the pupil and promoting the laceration of the 
false membranes which may have been developed in its vicinity. 
But it has been remarked, that in cases of intense iritis, the pupil 
does not dilate under the influence of the belladonna ; it was only 
after the inflammation had subsided, and the congestion dimin- 
ished, that dilatation was produced, and the laceration and separa- 
tion of the very thin grayish newly-formed adhesions were effect- 
ed. This shows the necessity of resorting to antiphlogistics before 
we use the belladonna. Every evening the belladonna should 
be freely rubbed over the eyebrows and on the eyelids. After the 
cessation of the acute symptoms, we may drop several times in a 
day a filtered aqueous solution of this substance on the conjunc- 
tiva. The medicine should be used regularly for a month at least 
when the pupil has not completely regained its natural mobility. 

Mercury, however, is the best of all means. It is on this medi- 
cine, says Mackenzie, that we should chiefly rely to arrest the 
progress of syphilitic inflammation of the iris, and to remove the 
morbid changes which may be produced in this membrane and in 
the pupil. It should not be administered in small doses as an 
alterative, but the system must be fully impregnated and the 
mouth evidently affected. In many cases, it is only after a copi- 
ous salivation is established, that any beneficial effect is observed 
from its use. 

I employ frictions twice in the day on the eyelids and the eye- 
brows, with a pommade composed of two-thirds of Neapolitan 
ointment, and one-third of the extract of belladonna ; afterwards I 
apply the Neapolitan ointment alone under the angles of the max- 
illary bones. In addition to the above, I administer internally 
two pills of the proto-iodide of mercury, daily. The mouth sooa 
becomes affected, even severely, producing an abundant discharge 
of saliva, and a rapid resolution of the iritis. I know of no treat- 
ment more rapid and effectual. 



406 VIDAL OJS" VENEREAL DISEASES. 

Mackenzie alludes to a case where the medicine was thrown 
aside by the family physician ; having been resumed, it produced 
but little benefit ; the patient, finally, having taken ten grains of 
calomel and five of opium, daily, for several successive days, the 
mouth became suddenly affected, and the iritis disappeared as if 
by magic This was a case of genuine syphilitic iritis, the pa- 
tient's body being covered with a copper-colored eruption. 

Mackenzie strongly recommends the combination of calomel and 
opium. A pill composed of one and a half grains of the former, 
and from one-third of a grain to one or one and one-third grains 
of the latter, may be given morning, noon, and evening, for some 
time, until the gums become decidedly affected; afterwards two 
pills a day may be continued for awhile, and when the salivation 
is of longer standing, we may diminish the quantity to one a day, 
to be taken in the evening. This combination is adapted to the 
severer cases, and when we wish to speedily arrest the progress 
of the malady, to prevent the effusion of lymph in the pupil, and 
to produce its absorption when already deposited. In the milder 
forms, we may rest satisfied in giving, to begin with, one pill 
morning and evening. 

Mercury, especially the proto-iodide, should be administered for 
a long time, not only that the iritis may be checked, and its con- 
sequences removed, but for the purpose of curing the constitu- 
tional infection, as we cannot infer the cure of the syphilis from 
the cessation of the iritis, and we should remember that the gene- 
ral disease often appears to be cured, though much still remains to 
be done, particularly with mercury, in order that the eye may be 
thoroughly cured of the iritis and its consecutive effects. 

I come now to speak of a means which has been highly praised, 
viz., turpentine. Carmichael of Dublin has reported cases in his 
memoir, presenting incontestable proof that this medicine has 
sometimes cured a form of iritis regarded as syphilitic. After the 
effusion of lymph in the pupil, and the formation of condyloma 
on the surface of the iris, he has succeeded in restoring these parts 
to their natural state. Carmichael was led to administer turpen- 
tine in iritis from the known influence of this remedy in cases of 
peritonitis, and the analogy existing between the morbid products 
in the two diseases, since in both a serous membrane is the part 
affected, and in both adhesions are produced between surfaces 
destined to be separated. This medicine, which, moreover, I have 
never administered, may be of service in some cases in which, 
from various circumstances, mercury cannot be employed. The 
oil of turpentine is given in drachm doses three times in a day. 
Its disagreeable taste, and the nausea which it produces, may be 
avoided by taking it in the form of an emulsion. If strangury 
supervene, the medicine should be for awhile suspended, and an 
infusion of flax-seed or camphorated julep be given. To prevent 
burning sensations in the stomach, we may add from four to five 
grains of camphor to eight ounces of the emulsion, containing one 
ounce of the turpentine. Conjointly with all these means, and 
even with the opiated frictions already mentioned, we should ad- 



DISEASES OF THE TESTICLE. 4Q7 

minister the sulphate of quinine, in cases where the nocturnal 
pains are severe. A pill containing one and a half grains of the 
quinine may be given when the patient retires, and another one 
hour before the expected paroxysm. 



SECTION Y. 

DISEASES OF THE TESTICLE. 

In the first part of this work I have described an affection of 
the testicles peculiar to the so-called primitive venereal diseases • this 
affection is orchitis, a lesion which is almost always of an acute 
nature. The disease now under consideration follows other syph- 
ilitic manifestations ; it is one of the most remarkable forms of 
consecutive syphilis ; it is the syphilitic sarcocele or the venereal tes- 
tide, a malady essentially chronic. 

SYPHILITIC SARCOCELE, OR VENEREAL TESTICLE. 

This chronic engorgement of which Astruc had a faint glimmer, 
and which Benjamin Bell seems to have in view, was but imper- 
fectly known before the investigations of Dupuytren and Sir Astley 
Cooper. It is to modern writers that we must refer for the history 
of this affection., and several obscure points yet remain to be eluci- 
dated. 

[Among those who have most contributed to promote our knowl- 
edge on this subject, by pathological evidence, the names of Cus- 
ack of Dublin, and Dr. John Watson of New York, deserve a con- 
spicuous place. The paper of Mr. Cusack in the 8th vol. of the 
Dublin Jour, of Med. Science, Nov. 1835, though brief, is valuable, 
inasmuch as his remarks are based on the evidence afforded by 
eight pathological specimens. It is strange that neither Sir Astley 
Cooper nor Mr. Curling never had an opportunity of dissecting a 
syphilitic testicle {Curling on Testis, Am. Ed., p. 348.) Sir Ben- 
jamin Brodie refers to a case in which he examined a testicle 
thus affected, but the morbid appearances observed by him did not 
differ from those seen in chronic inflammation. (Lond. Med. Gazette, 
vol. xiii., p. 379.) The preparations presented to the Surgical So- 
ciety of Ireland by M. Cusack, exhibited the changes produced by 
the disease " in all its stages of progress, from a small circumscribed 
tubercle in an otherwise sound testis, to the contracted, indurated, 
and completely disorganized gland," which changes were analo- 
gous to the products of scrofulous disease. The several examina- 
tions made by Dr. "Watson led him to conclude that the primary 
seat of the affection is in the fibrous envelope forming the proper 
capsule of the testis, which occasionally becomes enormously 
thickened, whilst the proper tissue of the testis remains healthy. 



408 VIDAL ON" VENEREAL DISEASES. 

The tubule seminiferi, with their continuous vessels of the epididy- 
mis were atrophied, pale, and immersed in serous effusion. In one 
case, there was a deposit of a large yellow mass, irregular in shape, 
broadest in front, and apparently connected with the fibrous en- 
velope of the testicle, and extending backwards in the direction of 
the corpus highmorianune. This mass, by its pressure, produced 
atrophy of the tubuli seminiferi. ( Watson on Syphilis, Neiv York 
Journ. of Med. & Collat. Sciences, Nov., 1845.— G. C. B.] 

As I have already stated, syphilitic sarcocele is one of the most 
remarkable forms of consecutive syphilis ; it is also that affection 
which at its commencement perhaps furnishes the strongest argu- 
ment against the systematic arrangement of the syphilitic accidents 
into three divisions. In fact, the same tumor may be a secondary, 
a successive, and a tertiary accident ; for we see syphilitic sarcocele 
developed during the existence of chancre, and the eruption which 
is earliest manifested, or even when not preceded by syphilitic 
cutaneous eruption, and again it appears only in connection with 
the more profound and tardy forms of the eruption ; finally, it may 
not occur until the last stage of syphilis, with the exostosis ; then it 
is tertiary. I had in my wards for a long time three patients 
affected with this disease, and in whom existed these three connec- 
tions with other accidents. 

Symptoms. — If we would remove the obscurities surrounding 
the history of venereal engorgements of the testicle, it is necessary 
to establish two varieties. 

1st Variety. — A blennorrhagia has existed, and may still exist, 
but it is rarely alone, the patient most frequently having been 
affected with chancres. The tumor almost always commences in 
the epididymis ; at a period, generally advanced, of the disease, we 
may detect an effusion of greater or less quantity of serum, in the 
tunica vaginalis. Sometimes the testicle is affected simultaneously 
with the epididymis ; it may constitute the largest portion of the 
tumor, which is generally of considerable size ; it is ordinarily 
larger, more unequal and painful than in the second variety. It 
is in this variety especially, that the tumor is the seat of lancinat- 
ing pains like those of cancer. When the disease is of long stand- 
ing, we find both sides affected; then when we imagine that we 
are treating an ordinary orchitis, which shifts from one testicle to 
another, as is of frequent occurrence, we are frequently mistaken, 
for whilst orchitis ordinarily disappears on one side when the 
other testicle becomes affected, we here observe the tumor on one 
side increasing whilst that of the opposite side does not diminish. 
This is the engorgement of the testicle which M. de Castelneau re- 
gards as a chronic orchitis, and which other writers on syphilis 
consider to be a syphilitic testicle, and which, in my opinion, is 
both. Perhaps it would be more proper for me to say, that it is 
an orchitis complicated with syphilis, a circumstance which, gives 
it a decidedly chronic character. Thus, in this first variety, syph- 
ilis invades a testicle already diseased, already inflamed ; it attacks 
a testicle affected with orchitis. 

2d Variety. — This is observed in patients who have never been 



DISEASES OF THE TESTICLE. 409 

affected with, blennorrhagia, who even have never had any disease 
of the genital organs, since I have seen a case of syphilitic sarco- 
cele in a patient where the only antecedent disease had been a 
chancre on the lip. Generally, there has been a primitive ulcera- 
tion on the penis, and this has been followed by a syphilitic erup- 
tion. In the majority of cases, there are no premonitory symp- 
toms and it is only by accident that the patient discovers that 
there has been any alteration in his genital organs, or perhaps he 
may feel a sensation of weight, and inconvenience, and of dragging. 
It is rare that a dull pain in the loins, occurring chiefly during the 
night, precedes or accompanies this variety of syphilitic engorge- 
ment. The tumor is generally smaller than that in the first variety. 
Sometimes the epididymis is not involved in this augmentation 
of volume ; it seems perfectly atrophied by the compression which 
it suffers from the abnormally-developed testicle. The gland be- 
comes gradually indurated in patches, in zones ; these multiply and 
finally become united, the testicle only, enlarged without being 
sensibly altered in form, is of remarkable hardness. Both sides 
are affected more frequently than is imagined, but generally one 
is larger than the other, and this alone arrests the attention of the 
observer. If but one testicle is really affected at first, the other 
soon becomes involved. According to M. Ricord, the parenchyma 
of the testicle, after having suffered this syphilitic attack, becomes 
transformed into fibrous, cartilaginous, or osseous tissue ; it may 
undergo even a malignant degeneration. Sometimes the tumor 
ulcerates ; according to the same writer, this would then constitute 
a gummy tumor, which should be opened independently of the 
testicle, it being seated in the cellular tissue of the scrotum. 
Atrophy may be one of the consequences of this affection of the tes- 
ticle, but it is not constant. I have seen, in more than one in- 
stance, both testicles which had been completely affected with this 
disease, restored to their normal state and afterwards perfectly fulfil 
their functions. I have seen it followed even by hypertrophy of 
the testicle ; a case came under my observation, where the testicle 
on one side had been removed, and the other was affected with 
the disease under consideration, and yet this patient after he was 
cured, indulged to excess in coition. I shall refer to this fact in 
another place. 

This second variety, which affects especially the seminal gland, 
may occur even where no antecedent chancre has been observed ; 
it may result from syphilitic blennorrhagia. It is to cases of this 
kind that most of the obscurity connected with the history of the 
disease in question is to be attributed ; for the advocates of chronic 
orchitis, who almost always reject this second variety, attach groat 
importance to the antecedent blennorrhagia in establishing this 
same chronic orchitis. 

Generally, the tumors on both sides are not painful, when they 
belong to the first or second variety. If pressure be made some- 
what firmly, it produces the same amount of pain that it would if 
made on a sound testicle. This pressure may be productive of 
no sensation whatever. When pain does exist, if on one side, it is 



410 



VIDAL ON VENEREAL DISEASES. 



rather towards the inguinal region, and in the majority of cases y 
it is then caused by the weight of the tumor, when the latter is of 
large size. 

As I have already stated, I am now treating of chronic affec- 
tions. Their progress is slow, and they may continue for several 
years. If we observe a certain tendency to assume an acute char- 
acter, it is in the first variety, and affects the epididymis. In the 
great majority of cases, there is a decided alteration in the func- 
tions of the testicles. Sexual desire is diminished, and in some 
instances completely destroyed ; erections are then less frequent, 
and sexual intercourse, less sought after at first, at length becomes 
impossible. The secretion of semen is lessened, and is proved by 
the smaller number of animalculas which is in all cases observed. 
These lesions in function become much more decided when the 
disease involves more particularly the parenchyma of the testicles, 
and when both are involved. The second variety in this respect, 
is more grave than the first. I shall return to this subject when I 
come to speak of the prognosis of the disease. 

Diagnosis. — The diagnosis may be greatly simplified by observ- 
ing the general rule mentioned in a memoir which I read to the 
Academy of Medicine. I have stated that when there is a chronic 
engorgement of both testicles, the affection is necessarily benign ; 
it cannot belong to any of the forms of cancer, nor to the category 
of tumors caused by tubercles which are found at the same time in 
the internal organs. Syphilitic sarcocele, therefore, can be con- 
founded only with the chronic engorgement of the testicles, which 
is also regarded as a tubercular affection, but which is of a benign 
character as the viscera are sound. It remains, then, to distinguish 
syphilitic sarcocele from this chronic engorgement, or, if it be pre- 
ferred, from these benign tubercular tumors. Here the antece- 
dents and the concomitant symptoms afford us great assistance. 
The tumor, besides, in the second variety, is less irregular than in 
the strumous affection, and the induration involves the testicle 
itself, whilst in the strumous disease the testicle retains its normal 
elasticity. The first variety, that which was first described, may 
more readily be confounded with the engorgement in question, 
and so much the more easily as among the antecedents of both 
tumors a blennorrhagia may be found. But the strumous tumor 
is much more irregular ; there are portions of it which frequently 
become softened, and suppurate ; it is rare that the patient, at 
some period of the disease, does not experience pain, and pressure, 
even when slight, produces it. Syphilitic sarcocele, on the con- 
trary, may pass through all its stages, without ever being the seat 
of the least pain, and, in some instances, even pretty strong press- 
ure does not excite it. 

Treatment may throw some light on the diagnosis ; the iodide 
of potassium, indeed, in large doses, produces a prompt and de- 
cided effect on the syphilitic tumor, while the same medicine, 
administered in strumous cases, is long in exerting its influence, 
and its action is felt in the tumor only after the m whole system has 
been thoroughly modified by this agent. True, the prompt and 



DISEASES OF THE TESTICLE. 411 

manifest action of which I have spoken is produced only in the 
first variety, and it is rare to observe these effects produced when 
the iodide is employed in the other forms of syphilitic sarcocele. 
But this variety is very favorably influenced by mercury, used 
both externally and internally, while the effects of this agent are 
injurious in the strumous affection. 

Prognosis. — I have already indicated my opinion as to the prog- 
nosis in syphilitic sarcocele, when I classed it among the benign 
tumors of the scrotum. The prognosis is therefore favorable, 
especially since the iodide of potassium has been introduced into 
the therapeutics of certain forms of syphilis. There is no diversity 
of opinion on this point. The patient, then, has nothing to fear 
in general ; but what effect has the disease on the functions of the 
organs ? This is a serious question, which I have attempted to 
discuss in a paper read before the Surgical Society of Paris. 

A testicle affected with what is called syphilitic sarcocele doubt- 
less suffers profound modifications in its structure. I have already 
stated, that the organ niay become of a fibrous or a cartilaginous 
nature, or its parenchyma may become the seat of calcareous de- 
posits, in which case it becomes atrophied. Nutrition in the sub- 
stance of the organ is impaired, the organ itself is diminished in 
size, and after the cure of this kind of sarcocele, it remains more 
feeble and of smaller size. Atrophy of the testicles, therefore, is a 
condition so frequently produced by syphilitic sarcocele, that we 
are authorized in assigning it a place among the general characters 
of the disease. But I believe that those who regard atrophy as 
an inevitable termination of syphilitic sarcocele, entertain an opin- 
ion not warranted by facts, or, more properly speaking, by well- 
authenticated facts. The consequences of atrophy of the testicles, 
as regards their functions, may be imagined, since if it exist to any 
great extent, if it involve the parenchyma of both organs, it is 
equivalent to castration. Unfortunately such a condition some- 
times happens. Thus, I was consulted by one of my confreres, 
who had watched the wasting of his testicles under the influence 
of syphilitic disease ; a portion of the epididymis only remained 
on either side, and these remnants of the organs were exceedingly 
sensitive ; impotence in this case was complete. This was an ex- 
ample of atrophy with its most serious consequences. The most 
common result of the disease is to diminish the size of the testicle 
in its ensemble only, and to render it irregular and of unequal 
consistence. 

The extent to which virility is impaired, does not appear to be 
always in proportion to that of the destruction in the organ pro- 
duced by the disease : indeed, we meet with patients no _ longer 
capable of an erection, or in whom the seminal discharge is very 
diluted, and small in quantity, and yet who have lost but a small 
portion of the parenchyma of the testicle. These differences de- 
pend upon the age of the patient, the use or abuse he has made of 
his virile powers, and the state of his mind. In connection with 
the latter point, melancholy cases are sometimes observed ; they 
occur in that class of society capable of comprehending the nature 



412 



VEOAL ON VENEREAL DISEASES. 



of atrophy of the testicles and its effects on virility. These un- 
fortunate individuals have learned the nature of indurated chancre 
and its consequences, of syphilitic sarcocele and its results : they 
remain a long time under the influence of disease ; they imagine 
an impotence with which they are often not affected ; they are 
afraid of marriage, regarding themselves as ruined men, and they 
remain in a state of celibacy the most melancholy and complete. 
If certain considerations, family or self-interest, lead them to con- 
tract marriage, at the moment of attempting the conjugal rite, their 
courage fails them, and they sink into the deepest despair. I 
knew a person placed in the above circumstances, and who after- 
wards became a father, after having been persuaded that even 
when both testicles are diseased, provided the patient be placed 
under proper treatment, virility may be preserved. This fact of 
itself is calculated to impress upon our minds the importance of 
the subject now under consideration. 

[These remarks of our author will doubtless recall those made 
in another place on Syphilophobia. — Gr. G. B.] 

For my own part, I believe, not only that atrophy followed by 
impotence are not the inevitable consequences, even when what 
we call syphilitic sarcocele is cured, but I am acquainted with 
facts which led me to think that, in certain cases, the testicle thus 
affected may, after a well-directed treatment and cure, preserve its 
vigor, and be completely restored to its normal anatomical and 
physiological state. A rare exception is where the same syphilitic 
influence, exercised on the same individual, produces completely 
opposite effects in each testicle ; one will become atrophied, the 
other hypertrophied. I shall soon relate a case showing this 
double effect of the syphilitic action. 

I have already published the details of one of the strongest cases 
to show that virility may survive a profound syphilitic affection 
of the testicle ; this case is related in my work on surgery, and 1 
shall repeat it when I come to the subject of the therapeutics of 
this disease. The patient was a soldier, from whom an army 
surgeon removed one testicle, supposing it to be affected with 
malignant disease ; in investigating the previous history of the 
case I found that the patient had had symptoms of syphilis. I 
prescribed the iodide of potassium in what I call sufficient doses. 
The testicle soon returned to its normal state, with the exception 
that it remained somewhat larger than natural. I ask the atten- 
tion of the reader here particularly to the last part of the report, 
which thus concludes: " The patient is constantly inclined to sexual 
indulgence. 1 '' I am convinced of the truth of this by the fact that I 
have been called upon to treat this soldier twice for blennorrhagia 
since he left the hospital. Here we have a patient with only one 
testicle, and that affected with what is called sarcocele ; the previ- 
ous history of the case, the characters of the tumor, the good effects 
of the iodide of potassium, all go to prove the fact ; yet this testicle, 
after the disease is removed, was not only not atrophied, but seems 
to have been hypertrophied ; his virility was not destroyed, for he 



DISEASES OF THE TESTICLE. 413 

indulged in sexual excesses, the penalty of which was repeated 
attacks of blennorrhagia ! 

In the month of August, 1847, there was in my service at the 
Hopital du Midi, a carman, who presented an analogous case to 
that just described. This patient had never lost a testicle, but one 
was not developed ; it was the right testicle, and was situated near 
the external opening of the inguinal canal, where the only trace 
of it to be found was the epididymis, which was scarcely the size of 
a common bean. This carman left my service cured; he after- 
wards contracted a chancre at a house of prostitution, communi- 
cated it to his wife, who became pregnant and gave birth to a child, 
which died shortly after its birth, covered with a syphilitic erup- 
tion, similar to that which I observed on its unfortunate mother. 
Here, again, was a subject with only one testicle, and that evidently 
syphilitic, and yet his virility was not affected, since it was mani- 
fested both in lawful and illicit intercourse, and by the birth of a 
child bearing the marks of the paternal disease. 

The following case would seem to prove that a syphilitic affection 
involving both testicles, may produce atrophy in one alone. M. 
Eicord asserts that this atrophy is consective to an actual disease 
of the testicle, of the existence of which we may be ignorant, since 
it does not augment the volume of the organ. For my own part, 
I consider it of but little consequence whether the atrophy is primi- 
tive or consecutive ; what I maintain is, that there may be atrophy 
of the testicle on one side, and hypertrophy of that on the other. 

On the 19th July, 1845, there was admitted into my service a 
man named B., set. 50, a road-laborer, and of good constitution. 
Twenty years before he contracted a chancre, which was followed 
by a suppurating bubo in the left groin. At the end of ten days 
the chancre became cicatrized, but the patient was confined to his 
bed awaiting the cure of his bubo. He took pills, but does not 
know whether they contained mercury ; he never had an eruption 
on his skin, nor sore throat. Six years since he suffered, without 
any apparent cause, pains in his head, neck, and extremities, which 
lasted only fifteen days. Three months since he contracted a new 
chancre on the anterior part of the reflection of the prepuce ; the 
only treatment was cauterization, and it cicatrized in the course of 
fifteen days. This patient never had a blennorrhagia. Some two 
months before the appearance of the last chancre, the left testicle 
began to enlarge, and this enlargement was unattended with pain. 
It is only during the last month that the patient has experienced 
shooting pains, which are more frequent during the night than the 
day. The left testicle at present is of the size of a large hen's egg-, 
it is hard, heavy, of pyriform shape, and presents slight inequali- 
ties. The epididymis cannot be felt, but appears to be confounded 
with the testicle. The spermatic cord is somewhat larger than 
natural, and the veins of the same side are also unusually developed, 
Pressure produces but little pain. A month and a half since a 
small tumor appeared on the external and superior part of the loir 
thigh, which suppurated. The wound was not completely cica- 
trized until about eight days since ; a very large reddish cicatrix 



414 VIDAL ON VENEREAL DISEASES. 

remained, analogous to those left by cutaneous tubercles. The 
right testicle is atrophied, being reduced to half its size. This 
diminution in size was not preceded by any tumefaction, and 
occurred about two months after the left began to enlarge, and at 
a time when discutient plasters had been applied to the latter, lead- 
ing the patient to suppose that the atrophy of the right testicle had 
been produced by the plaster. 

July 12th. The iodide of potassium was administered to the 
extent of half a drachm daily. Eight days afterwards the pains 
had ceased, and there was a marked diminution in the size of the 
testicle. 

28th. The left testicle, which was the largest, is reduced to 
nearly half the size it presented on the patient's admission. In- 
durated nuclei are felt much more distinctly when the testicle is 
made to glide beneath the skin under the ringers ; the consistence 
is less. The epididymis is readily distinguished from the rest of 
the gland, and the spermatic cord has regained its normal size. 
There is no longer pain even on pretty firm pressure. The nor- 
mal sensibility seems to be diminished. For some days past the 
patient has been troubled with dimness of vision. The vessels 
radiating from the sclerotic are slightly injected ; there is photo- 
phobia, with lachrymation. The patient also complains of buzzing 
in his left ear, but this has existed for several years. 

Aug. 8th. Vision is now perfect, and the eyes have resumed 
their natural appearance. The buzzing in the ear continues. The 
indurated nuclei in the left testicle are less numerous and painful. 
The consistence still diminishing. 

22d. The left testicle has regained its normal shape. It still 
remains larger than natural. The right is always small — that is, 
it is reduced one-half. I saw this patient again one month after 
his cure; he came to consult me in regard to a blennorrhagia 
which he had contracted. 

Here, then, we have three cases establishing the fact that both 
the testicle and its functions may be preserved in their integrity 
after the termination and cure of a syphilitic sarcocele. They jus- 
tify me in placing hypertrophy of the testicles in the same cate- 
gory. I will not conceal the objections which may be urged 
against my conclusions, objections drawn from the cases them- 
selves which I have quoted. In the first place, it may be said, that 
hypertrophy of one testicle in the absence or imperfect develop- 
ment of the other, is a fact in the organo-genesis well known ; that 
the hypertrophy preceded the syphilitic infection. Syphilis, there- 
fore, did not give rise to it ; it resulted in obedience to that law of 
compensation, by which the materials destined for the' nourish- 
ment of an absent or imperfectly-developed organ, are carried to 
its fellow organ, which thus receives an unaccustomed supply. It 
may be objected, perhaps, that in the cases above mentioned, 
syphilis has found the testicles hypertrophied, and that if after its 
cure, the testicles remain of their natural, or of an unnatural size, 
if they still retain their functions, it is no proof that these organs 
have not suffered a certain degree of atrophy, for an organ which 



DISEASES OF THE TESTICLE. 415 

is equal to one and a half may very well suffer a substraction, and 
remain still equal, if not a little more larger than the other. The 
case of the carman furnishes the strongest argument in favor of 
this view of the subject ; he was born with but one perfectly-de- 
veloped testicle, whilst the situation of the other was indicated 
only by a portion of the epididymis. There may therefore be 
some ground for believing the perfectly -developed testicle, in this 
case, had become considerably enlarged before it became diseased. 
When attacked by syphilis it became reduced to less than its na- 
tural size: the hypertrophied organ here became atrophied, and 
the hypertrophy was at the expense of the cure. These arguments, 
to which I cannot refuse a certain value, do not destroy the fact of 
one testicle retaining its natural size, with a volume even more 
than natural, preserving its functions, and this, too, after it has 
suffered from the disease called syphilitic sarcocele. I do not 
know precisely what was the condition of the left testicle in the 
carman before it became attacked by syphilis ; what I affirm is, 
that, after the cure, it was found of larger size than the same organ 
in another subject of the age and strength of that patient. I will 
also state, that this carman, who had begotten no child before his 
disease, did so after his cure. 

The same objections, perhaps, may be advanced against the case 
of the soldier in whom one testicle had been extirpated, and who, 
after being cured of syphilitic sarcocele in the other, preserved the 
latter in an hypertrophied and very active state, for there was an 
interval of two years between the castration of the one, and the 
syphilitic attack in the other. During this period, it may be said, 
the testicle which was left had the benefit of the nutritive mate- 
rials destined for the other as well as for itself, and may have thus 
become preternaturally developed : constituting an hypertrophy, 
which may have prevented the atrophy from producing its effects. 
To this I will reply, in the first place, that the two years' interval 
above mentioned, was too short a period for an organ to become 
so hypertrophied as to resist the atrophy produced by s} r philis. 
Further, as the whole history of this soldier's disease, a history 
which may soon be read, proves to me that the amputated testicle 
was not cancerous, but syphilitic ; and, as it was the same venereal 
disease with which the first was affected that invaded the latter, I 
submit whether a subject, completely infected with syphilis, under 
the influence of a principle the tendency of which is to produce 
atrophy of the testicle, could, under such circumstances, have one 
of these organs hypertrophied. I believe, further, that the altera- 
tions of tissue constituting the tumor, called syphilitic testicle, or 
syphilitic sarcocele, may vary, and that the mode of reparation is 
not always identical ; in proof of this, I will offer the case which I 
have fully related. It shows, indeed, that under the same syphili- 
tic influence, one testicle becomes atrophied without becoming 
tumefied, while the other tumefies, actually forming a tumor, and 
remains, to a certain extent, hypertrophied. These facts and these 
inferences are, in my opinion, of a nature to merit the attention of 
practitioners^ for they relate to an important question in pathologi- 



416 VIDAL ON VENEREAL DISEASES. 

cal anatomy, and to the question of sterility in the male — questions 
of very serious importance, in many points of view. 

Treatment — The treatment is the same as in confirmed consti- 
tutional syphilis, modified, however, according to the variety of 
the sarcocele and the other circumstances already indicated. We 
should remember that syphilitic sarcocele does not always occur 
at the same period of syphilis. I have asserted, at the commence- 
ment of this article, that the tumor may appear shortly after the 
first manifestation of syphilis, simultaneously with a premature 
eruption on the skin, or without this eruption, that it has been 
observed during the period of transition, and that, in fine, it *may 
occur among the latest symptoms, such as periostosis and the 
exostosis. The practitioner should take these circumstances into 
consideration. The sarcocele which appears before this profound 
alteration of the organism, which contra-indicates all depletory 
treatment, may be advantageously affected by mercury. It was 
this variety of sarcocele, which I will call premature, that was cured 
with mercury alone, by Dupuytren, Boyer and other practitioners, 
who, before they decided to perform castration, subjected to a mer- 
curial treatment patients affected with chronic enlargement of the 
testicles, which assumed certain of the characters of cancer. Thus, 
more recently, with the pills of the proto-iodide^ of mercury, I 
have removed a double syphilitic sarcocele, which had preceded 
the squamous eruption. Mercury, therefore, and even mercury 
alone, may radically cure certain syphilitic sarcoceles, and I be- 
lieve that it is well to commence with it, when we have a concom- 
itant superficial eruption, and the patient still retains his strength, 
and his constitution is not profoundly altered. It is, in my opin- 
ion, the means for preventing relapses. But it is evident that cer- 
tain sarcoceles, especially those of the second variety, cannot be 
affected by mercury, no matter how it may be administered. This 
remedy, therefore, may have its dangers, and it is principally 
when the disease is late in its development, when it occurs in the 
last stages of syphilis, when the syphilitic cachexia is already es- 
tablished. These are the sarcoceles which were formerly re- 
moved by castration ; they were regarded as of a cancerous na- 
ture, because they resisted the influence of mercury. This period 
is not very remote from our own, and I have seen, quite re- 
cently, some of the great masters whom I have mentioned remove 
testicles which might have been saved by the iodide of potas- 
sium. 

[Dr. John Watson refers in his Essay to an instance where, in 
consultation, he opposed, but unsuccessfully, the operation of cas- 
tration for syphilitic sarcocele ! — Gr. 0. B.] 

This, therefore, is the remedy to be employed in severe cases, 
when the constitution has become compromised; in the second 
variety, then, it will produce very prompt, and at first, very de- 
cided effects. Its employment even need not be confined to the 
latter variety ; as a general rule, it should, be associated with mer- 
cury in the treatment of the first variety. The following is a re- 
port of the case to which I have alluded ; it is calculated to make 



DISEASES OF THE TESTICLE. 417 

the surgeon reflect in similar cases, and to cause the surgeon who 
performed the operation to regret the deed. 

Great enlargement of the left testicle. Ablation of the organ by an 
army surgeon ivho regarded the tumor as a hydro-sarcocele. Similar 
enlargement of the right testicle. Cure by the iodide of potassium. — 
B., set. 29, gunsmith, occupying No. 24, Ward 10, admitted 11th 
of March. Not very robust, and of a scrofulous aspect. He states 
that from his childhood he has never been ill. His parents are 
healthy, and are very vigorous. On his neck and face, however, 
are cicatrices which have resulted from scrofulous ulcerations. 
Six years since, he had a blennorrhagia, which lasted eighteen 
months ; this was never painful, and was cured spontaneously. 
Six months afterwards, long after he had indulged in sexual inter- 
course, ulcerations appeared on the prepuce and glans. The 
patient submitted to a mercurial treatment. After this, he had an 
eruption on the skin, which the physician did not regard as syphi- 
litic, according to the patient's statement, and there was an enlarge- 
ment in the left axilla, without any abrasion or wound of the cor- 
responding extremity ; perhaps it was a scrofulous bubo, and it 
was treated by maturatives and an incision. The patient states 
that there was a syphilitic ulceration in his mouth, which his 
physician repeatedly touched with the nitrate of silver, and which 
healed several times only to break out again. At length, the left 
testicle began to enlarge (the patient being at this time in service) ; 
in the course of four months it acquired an enormous volume ; 
hard at the commencement, it became softer and softer ; more or 
less frequent shooting pains were felt in the tumor, extending 
even to the kidneys. For four months the patient remained in 
military hospital. Finally, in April 1841, the tumor was removed 
by operation. The wound, at the end of six weeks, had completely 
cicatrized. The man resumed his occupation as gunsmith. 

Two years afterwards, the right testicle became enlarged. In 
the month of August, 1843, this enlargement had acquired the 
volume of the two fists. It was hard, particularly at its inferior 
part ; it was the seat of severe lancinating pains, which deprived 
the patient of all repose. His physician prescribed the repeated 
application of a large number of leeches to the tumor, frictions 
with mercurial ointment, and the plaster of Yigo. Six weeks af- 
terwards there was a great improvement; but the patient led an 
irregular life, and was addicted to excesses. Although deprived 
of one testicle, and the other was diseased, he had strong sexual 
desires. After his indulgences, his pains returned with still greater 
severity. He then resolved to place himself under my care, and 
he was admitted into the Hopital du Midi, The tumor was much 
larger than the fist ; it was hard at its posterior and lateral parts ; 
somewhat soft anteriorly, and there was a sense of fluctuation for 
the extent of about one inch ; its shape was oval, its upper extrem- 
ity the largest, and it had much the appearance of the swelling" in 
hydrocele ; but it was much heavier than the latter. As I have 
already stated, this tumor was the seat of severe lancinating pains. 
The particular hardness of this tumor, the nature of the pains, the 

27 



418 VIDAL ON VENEREAL DISEASES. 

circumstance of the ablation of the other testicle, seemed to show 
that it was a true sarcocele, a scirrhous or encephaloid tumor 
which might lead to a fatal termination. But having carefully 
learned the history of the disease, on his admission, I placed him 
under the influence of the iodide of potassium ; he had taken only 
about two drachms before the pains had nearly ceased. At pres- 
ent, April 15th, 1844, the tumor is reduced one half in size, and 
the pain has completely subsided. 

The part of the tumor presenting an obscure fluctuation has not 
enlarged, but there is still a sensation of a fluid of this consistence, 
as if it might be the product of ramollisement. On the 2d of May, 
1844, the indurated portion had diminished in extent, fluctuation 
was more evident, and the whole tumor was less than half its orig- 
inal size ; on the 19th of May, it was scarcely double the volume 
of an ordinary testicle. The administration of the iodide of potas 
sium was suspended. Frictions were made on the tumor with an 
ointment of the iodide of lead. Finally, the testicle resumed its 
normal state, and the patient left the hospital on the 15th of June. 
He is always strongly inclined to sexual indulgence. 

"We here see a tumor presenting many of the characters of ence- 
phaloid disease; an obscure fluctuation, lancinating pains, debil- 
ity, pallor of countenance, one testicle amputated, a testicle which 
was similarly affected, and yet the iodide of potassium in this case 
was triumphant ! Did it cure a cancer, or was it a case of benign 
tumor, a syphilitic sarcocele ? The latter appears to me the more 
rational hypothesis. 



SECTION VI. 



DISEASES OF THE CELLULAR TISSUE. 

In describing the affections of the skin and mucous membranes, 
we have frequently alluded to a simultaneous lesion of the cellular 
tissue. Thus, the deep-seated syphilitic eruptions, the tardy lesions 
of the velum palati, of the pharynx and tongue, are attended with 
more or less congestion of the subjacent cellular tissue, and at the 
same time it is observed in the affections of the external and in- 
ternal tegumentary coverings. It is the diffused syphilitic indu- 
ration of the cellular tissue ; it may occur conjointly with the le- 
sions of the skin. In this case, the cellular tissue seems to become 
affected by the extension of the cutaneous lesion, or by that of the 
mucous membrane by which it is covered. At other times the 
cellular tissue becomes thickened, and indurated without any pre- 
vious affection of the skin, which may then remain for a long 
time and forever, in a normal state. 

Instead of this diffused or vaguely-circumscribed induration, 
we may observe partial engorgements, which gradually assume 
the form of a nut, tubercle or knot. They may be condyloma*- 



DISEASES OF THE CELLULAR TISSUE. 419 

and then they occur especially about th^ anus ; or they have re- 
ceived the names of gumma, nodes, gummy tumors, and are found 
beneath the skin, the deep cellular tissue, and even in the sub- 
stance of certain organs, and of muscles. This affection of the 
cellular tissue is observed when constitutional syphilis has deeply 
undermined the system. The most frequent seat of these tumors 
is on the external surface of the extremities, in the subcutaneous 
cellular tissue, where it is lamellar and dense ; there they may for 
a long time preserve a certain degree of mobility and for a decided 
prominence ; they have been seen of a pediculated shape. 

These tumors may occur in the cellular tissue of the scrotum ; 
they may then be confounded with syphilitic sarcocele, a mistake 
of no great importance, or they be confounded with genuine can- 
cer, an error of much more serious consequence. They may also 
occur in the deep-seated cellular tissue, and even in that which 
unites, or separates the fibrous or the muscular system. Thus they 
frequently invade the tongue, which then appears as if covered 
with small hazel nuts. M. Eicord mentions a remarkable case of 
the kind. It is in such cases that it is especially liable to be con- 
founded with cancer. 

Generally, there are several of these tumors, but they are not all 
developed simultaneously. Months, and even years, may there- 
fore be required to effect their cure, no matter what the treatment 
pursued. At first, they are small, but little sensitive, hard, adhe- 
rent to the skin, but free and movable beneath. They are slowly 
developed, increase slowly, and are unattended with pain. Some 
little inconvenience in the part, or accident, leads to their discovery 
by the patient. They vary in size from that of a hazelnut to a 
walnut. For a long time hard, they finally yield to pressure, pre- 
senting a slight sense of fluctuation, which afterwards becomes 
quite evident. Then, if they are in the vicinity of the skin or the 
mucous membrane, their envelope becomes thin, of a violet reddish- 
brown color, and they burst, presenting perforations similar to 
those which follow the opening of an anthrax. A badly assimi- 
lated pus, a kind of gummy matter, of organic debris, issues by the 
openings which become enlarged: a deep ulceration forms; the 
gummy tumor appears to be evacuated, leaving a kind of cavern, 
bounded by a shell, or cyst, which must be destroyed and cast 
out, before complete reparation can occur. The cicatrix that fol- 
lows is depressed, and irregular like that succeeding to a deep 
burn. 

M. Kicord observes that the ulcerative destruction which suc- 
ceeded to the tumors on the tongue, in the case before mentioned, 
"was horrible, and to eyes unaccustomed to such sights these ul- 
cers might have appeared horrible cancers."* 

We should remember, that all deep-seated syphilitic tumors are 
not formed by the cellular tissue, or at least by this tissue done. 
Thus, in describing the tumors of the muscles, I shall soon speak 
of one formed by a particular degeneration of the muscular libres 

* Traite des Maladies Venerieniics, p. 660. 



420 VIDAL ON YENEKEAL DISEASES. 

themselves. In complex cases, the tumor may be composed both 
of cellular tissue and th 'parenchyma of organs. 

The affections of the cellular tissue, of whatever form, are neces- 
sarily grave, as they occur at a period of syphilitic infection char- 
acterized by a profound alteration of the organism. The gravity 
of the prognosis, besides, depends upon the soat of the gummy 
tumors. Thus, those situated beneath the skin on the extremities, 
are of a much less serious character than those which are devel- 
oped in the substance of the tongue, or of the velum palati ; for 
when they ulcerate, they may commit vast ravages, and compro- 
mise important functions. 

The treatment must be adapted to the nature of the affection, 
and the period of syphilis in which it is observed. Mercury can 
seldom be administered with propriety in these cases, on account 
of the profound alteration of the organism coinciding with these 
tumors. The practitioner should therefore avoid this and all other 
hypothenisants, and trust to tonics, and such other means as may 
invigorate the system. At the head of these means, stands the 
iodide of potassium. If the subject tolerate it well, and it be ad- 
ministered in due season, we shall see these tumors rapidly disap- 
pear. Some have advised the application of blisters to these 
tumors, and that they should be opened, and even extirpated. It 
is evident that these proceedings cannot be resorted to except in 
certain cases, where the situation of the tumors renders them ac- 
cessible to the means indicated. Cullerier treated these tumors by 
blisters dressed with the bi-chloride of mercury, as is recom- 
mended by M. Malapert in the treatment of buboes. The opening 
of these tumors is but a palliative remedy, and their extirpation 
should not be attempted except when general treatment has been 
exhausted, and a satisfactory trial given to the iodide of potassium. 
Should, however, we attempt to extirpate them, we should do it 
thoroughly, for the suppuration will be rendered very protracted 
if any portion of the cyst be left behind. Sometimes the opening 
of the tumor, whether spontaneous or made by the surgeon, is fol- 
lowed by a very active inflammation. We must then resort to 
topical emollient applications. In the majority of cases, dressings 
with charpie, steeped in . a mixture of two-thirds water and one- 
third tincture of iodine, should be preferred. We may afterwards 
employ dressings with the vigo cum mercuric-, which will here be 
found a very useful application. 



section yn. 

AFFECTIONS OF THE MUSCLES, TENDONS, AND APONEUROSES. 

These organs of locomotion frequently become affected in the 
last stages of syphilis, and yet, until recently, the study of these 
lesions has been almost entirely neglected. Astruc merely alludes 



AFFECTIONS OF THE MUSCLES, TENDONS, &o. 421 

to this manifestation of syphilis ; according to this writer, when 
the snbstance of the muscles becomes infiltrated with the virus, we 
have ganglions, and hard tumors ; he speaks of rheumatic pains. 
Petit Eadel properly characterises it "a retraction rebellious to 
treatment." M. Lagneau seems to have observed analogous cases, 
and he regards the syphilitic contractions as chronic inflammations of 
the muscles, arising from the syphilitic infection. MM. Ph. Boyer 
and Eicord have clearly described these contractions, especially 
those seated in the flexor muscles of the fore-arms ; they place 
beyond doubt the syphilitic nature of this lesion, and its connec- 
tion with the tertiary symptoms. I have more than once observed 
the contraction of the brachial biceps, and have seen a tumor 
seated in the rectus femoris. The particulars of this case I will 
soon relate. Finally, M. Bouisson has treated, ex professo, this 
question of the syphilitic tumors of muscles and their appendages, in 
a memoir published in the Gazette Medicale of Paris, 1846. I have 
availed myself of this memoir in the present article. 

Causes. — The last effects of the diathesis are manifested by 
numerous local affections. It is the duty of the practitioner to 
discover the existence of this diathesis, and to assign to it its pro- 
per place in the etiology of these affections. Nothing is better 
established than its manifestations in the osseous and fibrous tis- 
sues, in what is called the tertiary form of syphilis, and these 
manifestations are generally produced by the influence of syphilis 
alone, without the intervention of any local or appreciable exter- 
nal cause. The syphilitic tumors of the muscles, and tendons, 
come under the same category ; they become developed in the sub- 
stance of these organs, independently of any particular exciting 
cause. 

Symptoms and Pathological Anatomy. — The principal symptoms 
are, pain, contraction and tumors. 

1st. Pain. — Pain is more especially observed when the syphilitic 
infection is inveterate, and in patients who have been exposed to 
the influences of cold and moisture ; these predisposing causes are 
not essential. This accident has been described under the name 
of syphilitic rheumatism. The pain is felt along the course of the 
muscles, tendons, and the aponeurosis of attachment or envelop ; 
it is of a character similar to that felt in osteocopes, but is less pro- 
found, and is exasperated by muscular contraction ; it differs from 
ordinary rheumatic pain by its relation to accidents evidently 
syphilitic, and it yields to specific treatment. 

2d. , Contraction. — The muscular contraction is sometimes the 
result of syphilitic rheumatism, of which it is but a higher degree ; 
at other times, it is slowly manifested, and coincides with a more 
or less advanced state of the disease. The muscles of the superior 
extremities, and more especially the flexors of the fore-arm, are 
most frequently affected with this contraction. M. Bouisson speaks 
of a syphilitic contraction of one of the motor muscles of the eve. 
According to this surgeon, if he were to name the seat of election 
of these contractions, it would be the sphincters. 

"We know," he observes, "how common are permanent con- 



422 VIDAL ON VENEREAL DISEASES. 

tractions of the sphincter ani, in subjects affected with syphilitic 
eruptions in this vicinity, and with fissures of the anus. We also 
frequently observe active and painful contractions of the vagina, 
in women affected with ulcerations in the vicinity of its vulvar 
opening. Now, if in certain cases, these spasms are provoked by 
the presence of ulcerations, independently of any specific influence, 
we do not violate the laws of analogy, in assigning in other cases, 
contraction of the sphincter muscles, a place among the accidents 
of confirmed syphilis, and in regarding it as a veritable venereal 
contraction," (loc. cit.) I know not precisely whether M. Bouisson 
does depart from the laws of analogy, but judging from my own 
observations, he abuses them. 

3d. Tumors. — Tumors developed in the muscular system and its 
appendages are deserving especial attention. I will first speak of 
the tumors of the appendages. 

The tendons and aponeuroses are more frequently the seat of 
syphilitic tumors than the fleshy part of the muscles. The tendons, 
like the periosteum, notwithstanding their feeble vascularity, par- 
ticipate in the effects of confirmed syphilis, and are especially liable 
to become the seat of partial thickenings, or of small tumors called 
nodes, which are sometimes hard and rilled, sometimes fluctuating. 
The pathological susceptibility of the aponeuroses, is here less 
marked, but different observations, and particularly those of Hun- 
ter, leave no doubt of the part which they take in this class of 
affections. It cannot, however, be denied that all the reports of 
'these cases are brief and unsatisfactory, and that they merely indi- 
sate their existence without affording us full details; it is even 
probable that in many of the cases where tumors have formed in 
these tissues from the effects of syphilis, and which have fallen 
under the notice of different observers, their real nature and causes 
have not been suspected. M. Bouisson has furnished the details 
and facts, which, as far as possible, have rendered the study of 
these affections complete. 

These tumors are sometimes solid, and appear to be produced by 
a circumscribed hypertrophy of the fibrous tissues of the tendons, 
with effusion of a serous and plastic fluid in their interspaces ; they 
are accompanied with pain more or less acute, which is increased 
during the contraction of the muscle to which the tendon is attached. 
The cadaveric examination exhibits this tendon of its natural color, 
or presenting only slight traces of injection; but it is enlarged 
either by the thickening of its fibres, or by the addition of an albu- 
minous and demi-sohdified matter. If the affection be long pro- 
tracted, if it does not terminate in suppuration, ossification occurs, 
and sometimes invades the whole length of the tendon, as was 
observed by M. Bouisson in the tendon of the psoas parvus muscle ; 
at other times it is limited to the part diseased, forming a kind of 
sesamoid bone. 

Syphilitic tumors occur both on the surface and in the centre 
of tendons. The first is the more common seat ; the tumor then 
forms an abrupt prominence along the course of the tendon, and 
it it terminate in suppuration the continuity of the fibrous cord is 



AFFECTIONS OF THE MUSCLES, TENDONS, &c 423 

respected. When it is situated in the centre of 4 the tendon, the 
newly -formed matter separates the fibres of the tendon and causes 
the tumor to assume an ovoid or fusiform shape. M. Bouisson 
has given an illustration of a tumor of this kind, taken from a 
preparation in the Museum of Pathological Anatomy of Stras- 
burgh ; it was situated in the substance of the tendon of one of 
the flexor muscles of the fingers. Fluctuation could be detected 
through the fibrous envelope, and the tumor presented nearly the 
form and size of an almond. 

According to M. Bouisson, the affection described by Lisfranc 
under the name of white nodosities of tendons was only a form of the 
syphilitic nodes found on tendons ; the case was that of a large 
tumor developed in the substance of the tendo-Achilles, in an opera 
dancer. It resisted every kind of local treatment ; but the iodide 
of potassium internally administered, aided by compression and 
certain antiphlogistic measures, produced a complete cure. It is 
to be regretted that Lisfranc has not furnished us with the previous 
history of the case ; but it is difficult not to assign this tumor a 
place in the category of those produced by syphilis, when we take 
into consideration not only the analogy between the situation and 
symptoms, but that in the effects derived from treatment. The 
iodide of potassium, the efficacy of which is well established in the 
accidents of confirmed syphilis, was pre-eminently the remedy if 
not the exclusive means of effecting a cure in Lisfranc's patient. 

The muscular tumors resemble those of the tendons. The essay 
of M. Bouisson contains several interesting facts relative to these 
muscular tumors, which have also come under my own observa- 
tion. It is sometimes difficult to determine whether this alteration 
has its starting point in the muscular fibre, or in the interposed 
cellular tissue. Analogy, observes the professor of Montpelier, 
would lead us to believe that the cellulo-sclerous tissue which 
unites the fleshy fibres, or which forms their sheath, is the part 
first attacked. But when the lesion is advanced, when it has 
manifested one of its modes of termination, either in suppuration 
or induration, all the anatomical elements would seem to be in- 
volved, and according to the more or less advanced state of the 
morbid action, the muscular fibres seem immersed in newly -formed 
matter; or, they become softened or destroyed, or transformed 
into indurated sub-cartilaginous and even osseous tissue. Such 
are the different conditions in which I at least have observed 
syphilitic muscular tumors. M. Kicord has dissected those taken 
from the tibialis posticus and from the ventricles of the heart, and 
in these cases they were evidently formed by the muscular fibres 
themselves. 

M. Bouisson divides into three degrees the modifications which 
the muscular tumors undergo. In theirs*! degree the muscle is the 
seat of a circumscribed local tumefaction, of a consistence exceed- 
ing that of oedema. A section of the diseased part displays some 
discolored muscular fascia, surrounded by a plastic effusion of a 
grayish color (a tumor of the gluteus maximus was of this kind}. 
This state may be indicated by a sub-acute inflammation, which 



424 TIDAL ON VENEREAL DISEASES. 

causes the morbid secretion which is to pass through further 
transformations. 

In the second degree, the effused matter becomes softened. If 
the inflammation continue with its original chronic character, the 
gradual elaborations of the effused product are transformed into a 
thready viscous fluid, similar to a solution of gum. Should an 
acute inflammation supervene, or there be a constant pain from the 
commencement, with an increase of the temperature of the part, 
true pus has then formed in the centre of the muscle, the softened 
fibres are destroyed, or are more or less considerably shattered. 
According to M. Bouisson, some cases of intra-pelvic abscess, 
arising from psoitis or destructive inflammation of the internal 
iliacus, may be the result of a syphilitic inflammation of the mus- 
cles in this region. In support of his opinion, he mentions the 
case of a soldier, affected with an inguinal bubo consecutive to an 
indurated chancre. Whilst in the hospital, this patient was seized 
with a chronic inflammation of the psoas and iliac muscles of the 
left side ; a tumor of considerable size formed in the pelvis, and 
protruded on a level with Poupart's ligament, and when opened 
by the bistoury, it discharges an enormous quantity of matter. 
The patient being subjected to an anti-syphilitic treatment com- 
pletely recovered. 

In the third degree, the non-suppurating syphilitic tumors become 
indurated. By successive stages of organization, they pass through 
the sub-cartilaginous, the cartilaginous, and osseous transforma- 
tions. The latter transformation is that which has most arrested 
the attention of pathological anatomists. M. Bouisson has seen in 
the Museum of the Faculty of Medicine, of Strasbourgh, an osse- 
ous mass of very considerable size, and which was developed in 
the body of the quadratus femoris. 

The ossification of the muscles and tendons often coincides with 
exostosis in different parts of the body. Prof. Dubreuil is in the 
possession of the skeleton of an Arab who was affected with syph 
ilis. In addition to numerous exostoses, there is ossification of a 
large number of muscles at their point of insertion. The osseous 
productions on this skeleton are of a styliform. laminated shape, 
or of various other configuration, according to the disposition of 
the muscles participating in the alteration. The seat of these 
muscular tumors is very variable. M. Bouisson has observed 
them in the gluteus maximus, the trapezius, the sterno-mastoideus, 
vastus externus, and some other muscles of the lower extremity ; 
he has also seen them in the pectoralis major, on a subject at the 
same time affected with a syphilitic perichondritis of the. costal 
cartilages. Finally, the same surgeon has observed, in the muscles 
of different regions, traces of ossification which might reasonably 
be traced to the effects of syphilis. I have already stated that M. 
Eicord has met with one of these tumors in the tibialis posticus. 

The following is an example of a muscular tumor, situated in 
the rectus femoris. It will be observed that it appeared after a 
deep-seated syphilitic affection of the extremities, with which there 
existed an exostosis. 



AFFECTIONS OF THE MUSCLES, TENDONS, Ac. 425 

July 24th, 1845. L., set. 38, was admitted into the Hopital du 
Midi. He was by occupation a groom, and of a sanguine tempera- 
ment. Six years before, he contracted a blennorrhagia, which 
lasted nine months. Three years and a half ago, he was under 
the care of M. Puche, for a left inguinal bubo, which appeared 
twelve days after a suspicious connexion ; he states, that on the 
day following this connexion, he discovered a slight abrasion, 
which disappeared in the course of two or three days. The bubo 
was very large ; it was opened, and suppurated but little. It was 
afterwards treated by compression. The patient was subjected to 
internal treatment, and remained two and a half months in the 
hospital. When he left, the tumor was very small, and it finally 
disappeared. Two months since, no accident had yet manifested 
itself; but at this time, pustules formed on the legs, especially on 
the left ; the patient states that they were about as large as the 
end of the finger; these soon broke, and from that time there 
were ulcerations at the various points which the pustules had 
occupied. At present these ulcerations are small, round, and ap- 
pear as if cut out with a punch ; they are situated on both sides 
of the leg, and number some six or eight ; the surrounding skin 
is of a violet-red color. Some are situated on the right arm, on a 
level with the epitrochlea. At the time of the eruption, the pa- 
tient suffered pains in his limbs, more particularly in his legs, and 
about fifteen clays afterwards, he discovered a prominence on the 
middle of the crest of the tibia ; this became the seat of a dull 
pain, which was more severe during the night. A physician who 
had probably mistaken these syphilitic for varicose ulcers, recom- 
mended the use of a laced-stocking ; but its application produced 
severe and intolerable pain. At present the tumor on the tibia is 
of the size of a walnut, of the hardness of bone, and painful on 
pressure ; the skin covering it is sound. Since the patient's ad- 
mission into the hospital, the pain has completely subsided ; and it 
is particularly when he becomes fatigued that it is rendered more 
intense. 

One day he discovered an indurated tumor on the anterior sur- 
face of the thigh ; it was painful on pressure, and when the patient 
extended his leg, the pain increased and became immovable. 
This tumor, which was about a quarter of an inch in diameter, 
could not be attached to the femur, as it was movable, nor to the 
skin, for it glided readily beneath it ; it appeared to belong to the 
rectus femoris, near the point of its insertion into the tendon 
uniting it to the patella. 

On the 26th of July, the patient was put upon the use of the 
iodide of potassium (half a drachm daily). For four days after 
commencing the use of this remedy, he was troubled with frequent 
sneezing and a considerable discharge of mucosities from the nose, 
accompanied with a severe obstruction of the passage. August 
10th, the induration on the thigh had sensibly decreased. August 
15th, the ulcerations on the legs, which had been covered with 
the plaster of Yigo, were cicatrized, and the enlargement of the 
tibia was diminished one-half. From this time, forty-five grains 



426 VIDAL ON VENEREAL DISEASES. 

of the iodide were given daily. August 30th, the tumor of the 
thigh as well as that of the tibia had disappeared ; the pain had 
ceased and the patient left cured. 

When the muscular tumors are somewhat voluminous, every 
contraction produces pain, and the latter, if it had previously ex- 
isted; becomes exasperated. Sometimes the affected muscle is re- 
tracted, as we have seen in the case of the psoas and iliac muscles. 
The tumors are movable or fixed, according to the state of relax- 
ation or repose of the affected muscle. If in a state of rest, the 
tumor may readily be examined ; it may be moved in various di- 
rections, thus distinguishing it from adherent tumors, and at the 
time we may appreciate most of its other physical characters. 
"When the muscle contracts the tumor immediately becomes fixed, 
according to the duration of the contraction, and this condition 
may also affect its degree of resistance and sensibility. 

The consistence of these tumors varies according to their du- 
ration and their mode of termination. Of a very moderate degree 
of hardness during their first stage, they present signs of fluctua- 
tion if the matter by which they are formed is converted into pus 
or a gummy matter ; at length they become quite hard, and if 
resolution be not effected, they are frequently attacked with a sub- 
acute inflammation. They are ordinarily of a globular form, their 
size varying from that of a small nut to that of an orange. The 
color of the skin remains natural, nor does the skin adhere to the 
tumor. There is no unusual heat, unless inflammatory accidents 
are manifested ; the lymphatic glands are sometimes enlarged in 
the vicinity, as we have seen in cases of tumors of the lips. 

The muscles of the tongue, lips, and of the movable portion of 
the palate, are affected with these tumors ; but pathological anatomy 
has not yet enabled us to distinguish those produced by a kind of 
muscular degeneration of tubercles which become developed be- 
tween, and separate their fibres, tubercles which by their elimina- 
tion, leave profound ulcerations. The different muscles of the 
larnyx itself, so often attacked in its mucous and cartilaginous 
elements, may likewise become involved. Finally, says M. Bouis- 
son, if it be true that the uterine tissue participate in the characters 
of muscular tissue, may we not comprise in the class of tumors 
under consideration, certain congestions of its cervix which result 
from the influence of venereal disease ? Long ago, I hinted at 
the connection existing between the tumors or tumefactions of the 
uterus and confirmed syphilis. On this subject, the reader may 
consult my remarks in my work on surgery.* 

Finally, the heart may be attacked by tumors analogous to 
those found in the muscles of animal life, at least this may be in- 
ferred from the report and illustration of a case in the Iconograjphie 
ofM. Kicord. 

At the autopsy of a venereal subject who died suddenly, M. 
Eicord discovered in walls of the venticles several points of a tu- 
berculiform alteration consisting of a hard yellow matter, creaking 

* Traite de pathologie externe et de medecine operatoire, t. v. 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 427 

under the knife, not vascular, of a scirrhous consistence at some 
points, at others, analogous to that of tubercular matter in process 
of softening. In a word, says this writer, we.there found the char- 
acters of syphilitic nodes or tubercles, tertiary accidents which are 
often observed in the subcutaneous or submucous cellular tissue. 
But in this case even the cardiac fibres were involved. I shall re- 
fer to this case in describing syphilitic affections of the viscera. 

Treatment. — The affections of the muscular system and its ap- 
pendages appear at an advanced stage of syphilis, and as I have 
already stated, conjointly with the deeper-seated cutaneous affec- 
tions, and especially with the lesions of the periosteum and bones, 
that is, at an epoch when, as a general rule, the system is debili- 
tated and but little disposed to tolerate the effects of mercury, 
which, besides, in the great majority of cases has been repeatedly 
employed. On this account we should discard this agent, or if 
we do resort to it, we should administer it cautiously, and carefully 
watch its effects. Iodine is the remedy generally indicated, and 
of all the preparations the iodide of potassium is to be preferred. 
It should be given in large doses. We have already described 
the mode of employing it ; the formulas which have received the 
most general approbation. We may dissolve half an ounce of the 
iodide, in eight ounces of water, and of this, "a spoonful may be 
given in a glass of hop tisane twice a day, by which half a drachm 
of the iodide will be taken daily. The quantity may be increased 
to six spoonfuls, that is to one and a half drachms, daily. But,' I 
repeat, it is seldom that I exceed forty -five grains in the day. At 
the same time, we may prescribe Bareges' baths, or vapor baths, 
especially the latter, if the patient is not too feeble. M. Bouisson 
states that he has advantageously employed, in some cases, the 
preparations of gold. I should prefer, in cases of great debility, 
and when the iodide of potassium has been administered for a 
long time, the ferruginous preparations, and afterwards resort 
again to the iodide of potassium, for it is always the best remedy 
in the last stages of syphilis. 

Local treatment is seldom indicated. Of course, when the mus- 
cular tumors are painful, and when this pain is aggravated by 
motion, and muscular contraction, repose should be observed, and 
local emollient applications prescribed. In other cases, resolution 
may be promoted by applying flying blisters, which should be 
repeated, and at the same time we should resort to the use of 
iodine ointments. 



SECTION VIII. 

AFFECTIONS OF THE BONES AND PERIOSTEUM. 

The bones and periosteum are so inseparably connected in their 
structure and diseases, that I shall consider them both under the 
same head. These affections, besides, resemble those of the skel- 



428 VIDAL ON VENEREAL DISEASES-. 



eton resulting from other causes. Here, as in all diseases of the 
bones, we have pain, inflammation, tumors, necrosis, and caries. 
But we most generally observe certain peculiarities in these pains, 
and a certain progress, and consequences of the inflammation, 
which, with other accompanying symptoms, give them a special 
character ; and finally, the effects of our treatment afford us aid in 
establishing the unity of their nature, for the same agent equally 
affects each variety. These shall be studied separately, and their 
treatment described. 



I_OSTEOCOPES. 

These pains accompany the lesions which I shall soon describe, 
but as they do sometimes exist when these lesions are not observed 
at the same time, they are separately described by many authors. 
If I conform to this custom, it is only that this symptom may be 
the more carefully studied. I do not, in fact, believe that this 
modification of sensibility is a separate disease, independent of 
any material lesion. When there is no external appearance of 
this lesion, it is because it has not yet completely formed, or 
rather that it is developed in a cavity formed by bone. Thus, the 
syphilitic disease, instead of being limited to the more superficial 
layers of the bone and the periosteum, may involve the deeper 
layers, the medullary membrane in the bones of the extremities, 
and the dura mater in the bones of the cranium and spine. In 
the latter case, the bone may continue for a long time, and even 
always diseased, without exhibiting any material external mani- 
festation ; and especially may this be the case, when only the 
internal membrane of the bone is affected. This is proved by the 
autopsies, which expose material alterations of the dura mater, 
exostoses of the inner table of the skull, without any external 
tumor. In my work on Surgery, I have given a representation 
of the frontal bone, in which two exostoses from the inner table 
of the skull projected into the cavity of the cranium, without any 
external protuberance whatever. This is what I call exostosis* 
and it is an affection which may produce the most atrocious pains, 
and even fatal cerebral compression, without its existence being 
suspected, unless the previous history of the patient be known. 
I shall necessarily return to the consideration of these internal 
tumors and their consequences. When the osteocopes continue 
after the disappearance of the apparent exostosis, there is reason 
to suspect that there has been, at the same time, an internal and 
an external exostosis, and that the latter alone has disappeared, 
while the first still remains. I repeat, an osteocope is but a symp- 
tom of an affection of the bones, and not a distinct disease. 

[In the London Journal of Medicine for October, 1852, (vid. also, 
Banking's Abstract, &c, No. 16, p. 128,) Mr. Henry Lee, one of the 

* Traiii de pathologie externe, &c, t. ii., p. 395. 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 429 

surgeons of the Lock Hospital, London, has published a paper, 
showing that long-continued pain in bone may depend, among 
other causes, upon the deposition of solid material, arising from 
the poison of syphilis. In the treatment of this affection, he re- 
commends the operation of trephining. This idea was suggested 
to him by a case which occurred at the Lock Hospital during his 
connection with it as house-surgeon. A young and delicate woman 
died after severe and protracted suffering from pain in the right 
thigh. On examining the bone, its cancellated structure was 
found occupied at different parts, by a morbid deposit of a light- 
brown color, of a moderately firm consistence, and which was dis- 
tributed in irregular patches. The parietes of the bone were 
greatly thickened, and a kind of cancellous structure had been 
developed between the original outline of the bone and the newly- 
formed portion. On the 29th of May, 1849, he operated on a 
woman, in whom the pain and swelling were confined to the im- 
mediate neighborhood of the knee-joint. As the epiphysis of the 
bone appeared to be the original seat of the disease, he trephined 
at this part. " As soon as the outer shell of bone was perforated, 
the cancellous structure was felt to give way under the press- 
ure of the instrument, and some minute and separate flakes of 
white matter were observed to escape with the blood by its side. 
On the 24th August, her health was quite restored ; she could 
raise her leg without any pain or inconvenience, and had expe- 
rienced no return of the 'old pain' since leaving the hospital." 
On the 19th October, 1852, Mr. Langston Parker read a paper 
before the Medico-Chirurgical Society of Birmingham, " On the 
Nature and Treatment of some painful Affections of Bone." In this, 
he states that the medullary membrane is liable to become in- 
flamed in the tertiary stages of syphilis, and owing to the un- 
yielding nature of the walls by which it is surrounded, this in- 
flammation produces at times the most atrocious pains. In a case 
of this kind, he perforated the medullary cavity with a trephine, 
and the hole thus made was kept open by a tent of lint changed 
every morning. The relief to pain was complete ; whilst previous 
to this operation, it had resisted all the usual remedies in such 
cases, blisters, opiates, iodide of potass, &c., and had at times been 
so excessive that she had frequently importuned me to amputate 
the limb." In gratefully acknowledging our obligations to the 
author for a copy of this interesting essay, we would observe that 
he recommends the trephine in cases of inflammation of the medul- 
lary membrane arising from scrofula, rheumatism, and wounds. — 
GvCB.] 

It is difficult to give a perfect idea of the character of these 
osteocopes. Sometimes, at the commencement, they seem to be 
wandering, the whole skeleton being painful. They are then 
often profound, that is, they come, in the language of the patient, 
from the marrow of the bones. In the majority of cases, they are 
fixed, yet not very clearly seated at any particular point of the 
skeleton. They are then acute, and lacerating ; the patient feels 
as though the bone were strongly pressed in a very narrow space, 



^30 VIDAL ON VENEREAL DISEASES. 

and as though it were being bored. Pressure in some instances 
does not increase the pain, whilst in others, it is aggravated by 
the slightest contact ; in this case, it is probable that there is peri- 
ostitis, or superficial ostitis. The most remarkable peculiarity of 
this pain is its nocturnal tendency. Indeed, it is sometimes com- 
pletely absent during the day ; at others, it is slight, and wander- 
ing, but it becomes aroused, fixed, and exasperated with the 
twilight, and is mitigated or subsides with the morn, which brings 
sleep to the sufferer. The pain is most severe during the first 
three hours of the night, and the paroxysm generally at its height 
about midnight. As these pains occur at the hour for retiring, 
and when the patient is warm in bed, this has been regarded as 
the exciting cause, and it is said that bakers who turn day into 
night, suffer from this pain during the day, that is, when they are 
in bed. But it should be remembered that bakers suffer more 
from heat when employed than they do in bed. Besides, instances 
have occurred where venereal patients have awakened, and remained 
in the open air, or have rode in a carriage during the night, and 
yet have suffered the same when the fatal hour arrived as when 
reposing in their warm couch. 

The diagnosis of these pains may be attended with difficulties. They 
are certainly more fixed than those of a rheumatic nature already 
described ; they return in the same place at each paroxysm, which 
is not the case with those belonging to the earlier stages of syphilis, 
and they are ordinarily exasperated by pressure, which generally 
relieves rheumatic pain. But these characters are not always so 
well marked, and I have already stated that there are wandering 
osteocopes, and some are not aggravated by pressure. True, the 
latter does not relieve them. Besides, the patient may have both 
rheumatism and .osteocopes at the same time, for we know that all 
the stages of syphilis are not perfectly distinct, and the accidents 
called secondary may occur simultaneously with the tertiary. It 
is not, indeed, very rare to observe a superficial cutaneous eruption, 
with an affection of the bone or periosteum. Still further, it is not 
always possible to distinguish syphilitic from rheumatic pains, for 
cases of osteocopes are observed in which the pain is exasperated 
during the day, and relieved during the night, and vice versd. 
Again, it is not very unusual for a patient to be affected both with 
rheumatism and syphilis, a circumstance which renders the diagnosis 
so much the more complex. Such cases have been observed among 
soldiers affected with the venereal disease who have contracted 
rheumatism in bivouac with washerwomen and hosiers. Thus, we 
see that pain alone may deceive the practitioner. The value of 
this symptom must be duly appreciated, but not exaggerated, and 
we must learn the previous history of the case, and examine the 
concomitant symptoms which may exist on the skin and mucous 
membranes, for we know that it is common to observe syphilitic 
eruptions or blotches during the existence of osteocopes, and it is 
not rare to find ulcerations in the buccal cavity, ulcerations mani- 
fested only by functional lesions of but little importance, and which 
may pass unobserved. 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 43I 

I am still compelled to add one word in relation to that error 
which attributes the osteocopes to mercury. This error has here 
assumed a serious character, for it is true that we may find mer- 
cury in the bones, and it is reported that M. Bretonneau has 
observed these pains in patients not affected with the venereal dis- 
ease, but whose systems have absorbed much mercury. As to the 
cases of M. Bretonneau, I have been unable to find them ; I can- 
not therefore judge of their value. Mercury has been discovered 
in precisely the bones which have never been the seat of any pain. 
It is known that workmen who are constantly exposed to mercu- 
rial emanations, do not suffer from osteocopes, and on the other 
hand, venereal patients who have abstained from mercury, have 
suffered in their bones and have had exostosis. Finally, these 
osseous pains and lesions have more than once been cured by 
mercury ; for before the introduction of the iodide of potassium, it 
was particularly by mercury that these accidents, peculiar to 
the last stages of syphilis, were combated. However, in order to 
omit nothing, I should add, that in a syphilitic patient who pre- 
sented cerebral symptoms, and who died after having taken much 
mercury, this metal was detected in the cerebral substance, (vid. 
the work of M. Eeynaud, p. 407.) 



IL— PERIOSTITIS AND OSTITIS. 

Periostitis, unaccompanied by ostitis, must be extremely rare if 
it does really exist, for the periosteum being but the envelope of the 
bone, it is difficult to comprehend how it should not participate in 
the affections of the latter. The same regions, the same portions 
of the skeleton, are most generally affected both by periostitis and 
ostitis ; thus the tibia, clavicle, ulna, radius, cranium, sternum, 
metacarpal bones, and the portions of these bones nearest to the 
skin. 

[According to Mr. Stanley, the osseous node does not occur 
upon the cranium. " So far does the pericranium differ from peri- 
osteum in its actions under the influence of disease, that under no 
circumstances does its tissue become ossified. When, from syphi- 
lis, isolated portions of the pericranium inflame, circumscribed 
swellings arise, which are hard and painless, when consisting only 
of the thickened pericraneum, but soft and tender when produced 
by serous or purulent effusion, either beneath the pericranium or 
into the cellular tissue covering it. In the latter case they have 
received the expressive designation of soft nodes." (Stanley on the 
Bones, Am. Ed., p. 271.)— Gk 0. B.] 



PERIOSTITIS. 

The tumor formed in inflammation of the periosteum, jpenosfosw, 
appears simultaneously with the pains already described, sometimes 
a few days after their first manifestation." This tumor, which 



432 YIDAL ON" VENEREAL DISEASES. 

grows on the portions of the skeleton just mentioned, is not dis- 
tinctly circumscribed ; it is rather an engorgement, the most promi- 
nent part of which is round, and the boundaries of which are 
insensibly lost in the adjacent tissues. The color of the skin is at 
first unchanged. Sometimes, there are several periostosis on a 
single bone, on the tibia or on a flat bone ; they are then smaller, 
there is a doughy feel around them, and yet the color of the skin 
is unchanged ; their progress is ordinarily, but not always, rapid, 
and, most generally, the pain which is severe, is still exasperated 
by pressure and by every movement of the corresponding bone. 
The tumor or tumors are much less distinct, much more difficult 
of diagnosis than when they spring from a bone deeply covered by 
muscular layers, as is the case with the femur. 

If the tumors are more superficial, so that they may be directly 
examined, we find them of a doughy feel ; then we detect a certain 
degree of fluctuation ; the skin at first sound, and movable over 
the tumor, finally adheres to it, becomes changed, and ulcerated 
if the disease terminate in suppuration. But this is far from being 
the most frequent result ; periostosis, on the contrary, may termi- 
nate in complete resolution ; it may also lead to the formation of 
exostosis, and this is a frequent result ; this is the variety which I 
shall describe under the name of exostosis epiphysaire. 

According to M. Eicord, periostosis may present itself under 
three different forms : 

1st. The first variety, often of a very indolent nature, but rapid 
in its development, is generally of long duration, and terminates 
in complete resolution. The tumor contains a serous, or a sero- 
albuminous fluid, resembling, in some instances, scrofulous pus, 
and in others, synovial fluid. 

2d. The second variety pursues the course of inflammatory 
tumors ; it is acute, and well marked, or it is sub-acute. Suppura- 
tion sooner or later occurs, and it is rare then that subjacent bone 
is not primarily or secondarily affected. 

3d. The third variety, of slower development, is, nevertheless, 
frequently very painful on pressure, and even when it is not 
touched. The tumor then consists of interlamellar plastic effu- 
sions, which may be the rudiments of exostoses, which we shall 
presently consider. 

[The degree of hardness of a node, says Mr. Stanley, does not 
with certainty indicate its composition. He states that he has 
examined those which, from their hardness, were supposed to be 
osseous, but found them to consist of indurated periosteum. — 

gk o. b.] 

I have already spoken of lesions of the periosteum and bone, of 
which there are no external signs, and which may produce the 
pains which I have already described. These internal tumors, 
when developed within the cavity of the cranium, cause disorders 
of a still more serious character, and here the dura mater, which is 
the internal periosteum, may play an important part. M. Eeeve, 
in a work entitled, Syphilitic Meningitis, has reported a case which 
would seem to belong to this class. It is as follows : 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 433 

11 Case. — M. F., in July, 1847, was attended by another surgeon 
and myself, for a paralytic affection : the rapid progress of which, 
together with other cerebral disturbances, alarmed the patient. 
He was unable to stand on his feet long enough to remove his 
pantaloons. His articulation was very imperfect, the combination 
of his ideas very defective, as well as his memory, and vision in 
both eyes considerably impaired. Some years before, this patient 
had been treated for secondary syphilis, which was manifested in 
the form of obstinate ulcers on the face and extremities. Shortly 
afterwards, he became affected with amaurosis, which continued 
to increase rapidly until it had terminated in the general paralysis, 
from which he was suffering when he came under our notice. 

"From an examination of the patient, and an inquiry into the 
previous history of the case, I was led to suppose that the symp- 
toms might depend upon a compression of the brain, produced by 
syphilitic tumors developed on the dura mater ; but to satisfy my- 
self more fully, I concluded to administer mercury in such a man- 
ner as to obtain its prompt and decided action. I directed that 
the whole scalp should be shaved, and covered with a blister, to 
the surface of which a drachm of strong mercurial ointment was to 
be applied twice a day. I was, however, alarmed by threatened 
coma, and the consequent prospect of a fatal result. 

" Eight days afterwards, I met the surgeon above mentioned ; he 
informed me that our patient became rapidly cured, and that he 
could now ascend and descend a very steep flight of stairs. To 
my great surprise, I one day met our patient in the street, in good 
health, vision perfect, and it was difficult to believe that it was the 
same person who had consulted me some three weeks before. He 
had completely regained the power of motion, sight, and articula- 
tion, and was in the perfect possession of all his faculties." 

The author expresses the opinion that the preceding case would 
certainly have soon terminated in death, had it not been for the 
administration of mercury. Such is his confidence in this agent, 
that, in a similar case, he should indulge the strongest hope of suc- 
cess, notwithstanding the most decided exhaustion in the state of 
the patient. It is a remarkable case of cure by mercury. The 
editor of the Gazette Medicate, from which journal I have copied 
the above report, states, that the preparation of iodine would have 
a still more decided effect in cases of this kind. I do not under- 
stand how such could be desired. 



OSTITIS. 

Syphilitic ostitis attacks the bones already mentioned as the seat 
of the nocturnal pains, viz., the tibia, clavicle, sternum, cranium, 
ulna, and radius. I have stated, that it is difficult to admit the 
existence of periostitis without ostitis ; indeed, the superficial layer 
of bone is always, or nearly always, involved in periostitis, and, 
most generally, it is the part first affected ; an effusion then occurs 
between this layer and the periosteum, by which the latter be- 

28 



434 VIDAL ON VENEREAL DISEASES. 

comes detached, and forms a tumor which may be detected if the 
bone be thinly covered. Instead of invading the superficial por- 
tion of the bone, ostisis may attack its parenchyma, and be there- 
fore deeply seated ; this is particularly the case, when it has ex- 
isted for some time without furnishing any external indications of 
its presence, of which pain is the only symptom. Ostitis, whether 
involving the externals portion, or the parenchyma of the bone, 
may be circumscribed — sometimes very limited, while, in other in- 
stances, it may be more extensive, invading the whole or nearly 
the entire bone. The bone, at first, presents here and there stains 
of blood, its vascular canals become developed, and contain red 
blood and a transparent fluid, resembling osseous substance ; fur- 
ther, these remarks apply to all cases of incipient ostitis, whatever 
may be their nature. A thicker fluid, resembling that of callus, is 
next secreted ; sometimes it is an organizable plastic matter, like 
that in certain cases of periostitis. The tumor, resulting from san- 
guineous congestion, and the products mentioned, often manifest 
themselves after the patient has complained of nocturnal pains ; at 
first it is very limited, and diffused ; there is no decided protru- 
sion, except in cases of circumscribed ostitis, and when a true ex- 
ostitis is about to form. 

Syphylitic ostitis is generally of a slow, chronic progress ; some- 
times it assumes a very acute form. 

A word as to the treatment of periostitis and ostitis. It is par- 
ticularly in cases of the former, of course external periostitis, that 
we may resort to topical applications and to certain operations. 
Thus, there are cases of exostosis evidently inflammatory, of an 
acute nature, and in which the patient still retains his strength ; 
we have then a formal indication for repeated local depletion by 
leeches. This first indication having been fulfilled, we may resort 
to the use of blisters. When the character of the tumor is less 
decidedly inflammatory, and the subject debilitated, the blisters 
may be employed without resorting to the local depletion by 
leeches. Their surface should be dres^d with mercurial ointment. 
Periostitis may also be treated by incisions. These, which have 
particularly been recommended in acute periostosis, by Crampton, 
MM. Yelpeau and Maisonneuve, should not be made except when 
the tumor is situated on a superficial bone, and when the iodide 
of potassium has been already administered internally, without 
effect. We may then reasonably infer that the resistance offered 
by the fibrous tissue to the expansion of the parts affected pro- 
duces a kind of strangulation, which may be relieved by the in- 
cisions which are then debridements ; but, I repeat that, first of all, 
the iodide of potassium should be tried, for in some instances the 
relief thus affected is equal to that produced by the incisions 
themselves. 

The treatment of ostitis, especially of superficial ostitis, does not 
differ from that of periostotis above indicated. Here we must par- 
ticularly avoid incisions, until we have administered internally a 
means the efficacy of which is so universally acknowledged, viz., 
the iodide of potassium. 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 435 

[The testimony; in favor of the iodide of potassium, as remarked 
by our author, is indeed universal, especially when the acute stage 
of periostitis has passed. "It rarely fails," observes Mr. Stanley, 
" to stop the progress of the disease, and, in much the largest pro- 
portion of cases, completely cures it. This statement of the reme- 
dial agency of iodide of potassium is to be taken in its most com- 
prehensive sense. Whether it be the inflammation of periosteum 
adjacent to an exfoliating bone, or investing an enlarged bone, or 
that which is the consequence of scrofula, syphilis or rheumatism, 
there has not appeared to me to be any difference in respect to the 
influence of this remedy upon the disease. And, with respect to 
the suitable doses of it, I have but* to repeat the statement already 
made, that my impression is in favor of administering it in doses 
of two or three grains, three times a day, in either decoction of 
sarsaparilla, or a bitter vegetable infusion, or camphor mixture 7 ' 
{op. cit. p. 275). Our own experience would lead us to rely 
rather on larger doses of the remedy ; we do not give less than 
five grains three times a day, and sometimes this quantity is in- 
creased to ten and even fifteen grains for a dose. — Gr. 0. B.] 



III.— EXOSTOSIS. 

A tumor actually exists in periostitis and ostitis, but the term 
exostosis is applied especially to the termination of these inflam- 
mations in induration. Indeed, instead of disappearing by reso- 
lution, suppuration, or mortification, the tumor formed by ostitis 
becomes the seat of excessive nutrition, of abnormal ossification. 
But periostitis or ostitis is not always necessary to the formation 
of an exostosis ; sometimes, indeed, we observe hypertrophy in- 
dependent of any previous inflammation; sometimes a plastic 
substance is deposited throughout the whole osseous substance, 
even in the medullary canal, a substance exactly resembling that 
mentioned when I was describing the syphilitic affections of the 
muscles. 

- Varieties. — As in other forms of exostosis, the syphilitic may be 
divided into two principal varieties ; the parenchymatous, and the 
exostosis epiphysaire. 

1. Parenchymatous Exostosis. — This occurs, especially, in cases 
of profound ostitis. The abnormal ossification may assume the 
character of areola, or of compact tissue. In the first case, it may 
consist of layers, between which are areola, constituting what au- 
thors denominate cellular or laminated exostosis. In the second case, 
it is the compact tissue, and according to Albers of Bonn, the 
cortical substance which constitutes the exostosis. If the osseous 
layers suffer a divarication, an osseous matter without any distinct 
organization has been deposited between them, and the volume of 
the bone becomes increased, but its weight and densit y have also 
undergone a marked increase. We have now the cbur natal exos- 
tosis, suitable for making scalpel handles. 

2. Exostosis Epiphysaire.— This results particularly from perios- 



436 YIDAL ON VENEREAL DISEASES. 

titis. Albers of Bonn, calls cases of this kind osteophytes, that is, 
new formations independent of the bone with which they are con- 
nected (at least for a certain time), since they can be removed 
without injury to the bone. Albers mentions an osteophyte (in 
the Museum of Bonn) situated on the middle of the femur of an 
adult ; it is of an oval form following the great diameter of the 
bone ; it has a compact envelope, and internally it is cellular. 
These are epiphyses, superadded bones, which, like all epiphyses, 
finally become incorporated with the bone ; at first they are sepa- 
rated by a cartilaginous or osseous layer, which disappears when 
this abnormal epiphysis becomes incorporated with the body of 
the bone. We meet with cases,, also, in which epiphytal exostoses 
are engrafted on those of the first category, on a parenchymatous 
exostosis: According to M. Kognetta, the epiphytal exostoses 
have a structure similar to that of velvet, that is, they are com- 
posed of fibres perpendicular to their surface of implantation. 

Whatever may be the variety of exostosis, its form will be more 
or less hemispherical ; it may . be conical, flattened, elongated, or 
even almost pediculated ; sometimes it is a crest similar to that 
formed in certain of the annular syphilitic eruptions ; an example 
of this singular form is represented in the Iconographie of M. Eicord. 
The epiphytal exostoses are the best defined, and form the decided 
prominences. 

Exostosis, particularly when large, may interfere with the func 
tions of surrounding organs ; and singularly alter their forms. In 
my work on surgery there is a representation of an exostosis of 
the superior maxillary bone, eleven inches in circumference, and 
which rendered the appearance of the patient hideous.* Some- 
times, then, only trouble is in the adjacent organs which may be- 
come displaced and atrophied ; thus, the exostosis of the superior 
maxillary bone to which I have alluded, at first interfered with 
the movements of the lower jaw, and ended in its dislocation. An 
exostosis may destroy the regularity in the movement of a limb. 
By compressing vessels, it may produce oedema at a greater or less 
distance from its seat, and by its pressure on nerves it may modify 
the sensibility of the parts, producing pain which must not be con- 
founded with the special pain seated in the exostosis itself. The 
effects of this compression are particularly severe, when the ex- 
ostosis springs from a bone entering into the formation of a cavity 
enclosing organs of great importance, as for example, the cranial 
cavity, or spinal canal. The compression of the nervous centres 
in these cases affects both the general and special sensibility, as 
well as the powers of motion, and the intelligence of the patient. 
A cranial exostosis may produce agitation, somnolency, para- 
lysis, convulsions and delirium. Amaurosis is sometimes the re- 
sult of an exostosis of the sphenoid or some other bone at the 
base of the cranium ; this ocular paralysis is not very uncommon, 
and we may remark in passing, that when it does depend upon 

* Traite de pathologie externe, &c, t. ii., p. 394, 3d ed. 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 437 

this cause, it generally affects but one eye. Exostosis of the orb- 
ital cavity, may produce other ocular paralysis and exophthalmia. 

[In the 28th vol. of the Loud. Med. Gazette, p. 45, is a brief no- 
tice of a case of strabismus produced by pressure from syphilitic 
lesions in the orbital cavity. The patient was cured by the bi- 
chloride of mercury. — Gr. 0. B.] 

Spinal exostosis is, in my opinion, more common than that of 
the cranium, but it most frequently remains undetected. I have al- 
ready mentioned my division of exostosis into internal and external 
exostosis : now, it is particularly in the former cases that the diag- 
nosis may be obscure, especially if, as I have remarked, we neglect 
to make ourselves acquainted with the previous history of the 
case. Thus, we may observe alterations of sensibility and of mo- 
tion without any apparent exostosis, nothing on the cranium indi- 
cating the osseous lesion, for it may involve only the internal 
table of the bone. There are properly no external exostosis on 
the spine, for the osseous trunk being in part concealed by the 
chest, abdomen, anterior organs of the body, and in part covered 
by muscular masses, frequently we may be unaware of their exist- 
ence until they have produced their most disastrous consequences. 
And yet, even then, if unacquainted with the antecedent circum- 
stances of the case, we may remain inactive, when had we properly 
inquired into the previous history of the case, we might have 
rendered essential service to the patient. In the great majority of 
cases, the syphilitic eruptions may direct us in our inquiries. 
Thus we may find one of these eruptions or some traces of their 
previous existence, but it may so happen that the exostosis shall 
precede the eruption. Then, should they afterwards appear, it 
will shed much light on the nature of the case. M. Debout has 
recently (June 1852) read to the Surgical Society of Paris an in- 
teresting essay on muscular paralysis. One of the cases reported, 
is that of the paralysis of a part of the superior extremity, the di- 
agnosis of which had been attended with difficulty. M. Nekton, 
who treated the patient, suspected the existence of an exostosis of 
the spine. It is stated, in the essay of M. Debout, that M. Nelaton 
was confirmed in his suspicions by the appearance of roseola on 
the skin. Here then the exostosis preceded the roseola, a second- 
ary accident generally quickly developed following a tertiary ac- 
cident ! This fact greatly compromises the harmony of the sj-ph- 
ilitic triad ; but the case was observed by one skilled in the clinique, 
and was fully reported in a serious essay which I heard read. 

I am about to relate the particulars of a case of paralysis of the 
inferior extremities which I considered the result of an affection 
of the bones of the spine, of an exostosis. I came to this conclu- 
sion by investigating the previous history of the case, and by a 
careful examination of the marks upon the skin, showing the an- 
terior existence of a syphilitic eruption of various degrees of depth. 
This case is remarkable not only in a practical, but is of great im- 
portance regarded in a doctrinal point of view. In fact, I inocu- 
lated the patient by means of a blister with the piis from a mucous 
tubercle, and I produced a specific ulceration, followed by a tu- 



438 VTDAL ON VENEREAL DISEASES. 

bercle of the skin similar to those in the syphilitic disseminated 
tuberclar eruption. This tubercle disappeared, leaving in its place 
a coppery-red spot, resembling those which continued for a long 
time on the patient's skin : so that this experiment, like that of M. 
Bourley, proves not only the inoculability of the secondary acci- 
dents, but also the possibility of a second attack of constitutional 
syphilis. The case has been fully and most carefully reported by 
my interne, M. Codet. I have omitted a number of details relating 
to the antecedents ; and have retained everything which goes to 
establish the fact that the subject had had confirmed syphilis, and 
that he was laboring under tertiary accidents at the time of inocu- 
lation. I shall hereafter profit by this case, and shall there give 
its complete details. This patient, besides, has several times been 
at la Pitie, where he was treated by two of my colleagues, and he 
was a long time in my service where he was observed by several 
physicians, and my students who watched the progress of the 
different stages of the inoculation. 

M., set. 37, admitted to the Hopital du Midi, Oct. 6th, 1851. 
First infection occurred on the 13th May, 1847 ; he had chancres 
on the penis. Afterwards was affected with blennorrhagia, orchi- 
tis, and disease of the eyes, one of which was lost. A gleet fol- 
lowed, and mucous tubercle about the anus. In June, 1850, the 
patient was in la Pitie, under the care of M. Piedagnel. At that 
time, there was a deep ulceration, of the diameter of a five-franc 
piece, on the the external surface of the left thigh. This was 
dressed with diachylon plaster and calomel in powder, and was 
cured in forty days. The cicatrix left by that ulcer is at present 
very distinct, being deep, and of a brownish-red color ; there are 
also scars on the legs, of the same color, but less profound. This pa- 
tient, who had had intense cephalalgia, now suffered somewhat less 
from this source, but he was attacked with pains in his legs. 

During the months of October and November, 1850, the patient 
worked at the leather dressing ; he suffered much from coldness 
and numbness of the feet. Walking was very fatiguing ; he 
dragged one leg ; and felt as though he was walking on cotton ; he 
became emaciated. His appetite was irregular. He became one 
of the watchmen to the Magdalen asylum. Here, the paralysis of 
his lower extremities daily increased. 

On the 10th Feb., 1851, he was again admitted to la Pitie, under 
the care of M. Becquerel. Sulphur baths were prescribed. The 
lumber region was cauterized, strychnine was administered, and 
electricity employed, but the paralysis constantly increased. The 
testicles became enlarged before he left his bed ; they were insensi- 
ble. A deep ulcer on the left leg yielded only to the application 
of the actual cautery ; eschars formed on the sacrum, and exposed 
the patient to the greatest risks ; he improved but slowly, and left 
the hospital but little relieved. Finally, on the 6th October, 1851, 
he entered the Hopital du 'Midi, suffering from a relapse. M. Vidal, 
having learned the previous history of the case, and struck by the 
aspect of the cicatrices, and the nature of the enlargement of the 
testicles, came to the conclusion that the paralysis proceeded from 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 439 

an affection of the bones of the spine, arid probably from an exos- 
tosis. The patient then was placed under the influence of the 
iodide of potassium, taking forty-five grains daily. At the end of 
two months he was able to rise and walk, though with difficulty. 
General condition excellent. The enlargement of the testicles, 
which was more marked on the left than the right side, diminished 
considerably under the use of the iodide. The patient regained 
his flesh, but wished to remain awhile in the hospital, awaiting 
an appointment from government. In January, 1852, a small 
blister was applied to each thigh on account of torpor of the blad- 
der ; it was dressed with charpie soaked in the pus from mucous 
tubercles with which the patient was affected. This was followed 
by no result. 

M. Yidal proposes to repeat the inoculation a future time. 

Indeed, on the 12th of April, 1852, the patient, complaining of 
suffocation, two blisters were applied to the external and superior 
part of each arm. 

April 13th. Both blisters were dressed with charpie, moistened 
in the pus of ulcerated mucous tubercles, on another patient. The 
inoculated subject experienced severe pains during the day. 

15th. The wound on each arm is covered by a grayish, very 
adherent, false membrane. Suppuration is very abundant, and of 
a sickening odor ; charpie, steeped in the same pus as that on the 
13th, is }3laced on the blistered surfaces. , * 

16th. The false membrane, at certain points, is wanting; a very 
red and granulated surface is perceptible, especially on the right 
arm. Dressings, soaked with the pus from mucous tubercles on 
another patient in the same ward, are applied to both blistered sur- 
faces.* 

17th. The blistered surface on right arm is the reddest, the false 
membrane has disappeared. No pain. From that time, both arms 
were dressed with simple cerate only. 

18th. A grayish spot, apparently slightly depressed, is discov- 
ered in the middle of the excoriated surface on the right arm ; on 
the left, the surface is of a vermilion red color ; a few grayish 
points are here and there hardly perceptible. 

19th. The small gray spot on the right arm has become slightly 
excavated ; on the left the blistered surface is dry. 

20th. The whole blistered surface on the right arm is red, with 

* M. Codet has made the following note of the patients from whom the pus for 
the inoculation was taken: 

Ward 11, No. 14.— A., painter, set. 41, admitted April 11th, 1852, left April 19th, 
1852. This patient had an indurated chancre in process of cicatrization. This 
chancre was of from two to two and a half months' duration. In addition to this, 
the patient discovered mucous tubercles about the anus and the geni to-crural fold ; 
these tubercles were the source of an abundant suppuration. On the 13th and 15th 
April, 1852, the patient in No. 32, Ward 11, was twice inoculated with pus from 
the tubercles about the anus of the patient in No. 14. 

M., traveller, set. 45, admitted March 15th, 1852, left May 23d, 1S52. Had a 
chancre in December, 1851; this cicatrized about the 15th January, 1852 ; tuber- 
cles appeared about the anus, January 20th, afterwards on the nose, chin, mouth, 
and in the axilla, &c. A single inoculation was made with the pus from the tuber- 
cles about the anus, on patient in No. 32, Ward 11, April 16th, 1862. 



440 VEDAL OX VENEREAL DISEASES. 

the exception of the central part, which is slightly depressed, and 
its gray color contrasts with that of the rest of the wound. The 
watch-glasses, which up to this time have been used to protect the 
wounds, are now no longer employed. 

21st. The surface of the small ulcer on the right arm has 
changed its color ; it is now dotted with red points ; there are soft 
and fungous fleshy granulations ; in other respects it has not in- 
creased, and has a diameter of about a quarter of an inch in every 
direction ; on its base, there is a small elevation reaching nearly 
on a level with its edges. On the left arm, there remains an unci- 
catrized surface of scarcely the diameter of a half-dime piece. 

2 2d. The small ulcer on the right arm presents the same appear- 
ance, only the red color exceeds the gray. 

23d. The ulcer on right arm seems to have become more regular ; 
the base is nearly horizontal, the edges well defined, the color 
about the same, the red preponderating. Left blister completely 
healed. 

25th. Instead of the small ulcer on the right arm, there is now a 
small hard tubercle, covered by a brownish crust, which remains 
in the place of the ulceration. 

26th, 27th, 28th, 29th, 30th ; 8th May. The small crust con- 
stantly remains ; it is removed, and beneath it is found a small 
ulceration, covered with pus ; its edges are distinctly defined, and 
ft has a grayish base. 

9th, 10th, 11th. The ulcer is slowly cicatrizing. 

14th. The small ulcer is covered with fleshy granulations, and 
it is touched with the nitrate of silver. There are some tubercles 
on the neck, about the roots of the hair, and on the upper lip ; they 
are covered with brownish crusts. 

18th. The little ulcer is on a level with the skin, but in its place 
is a small hard brownish red body, which is raised but little above 
the level of the skin, and which is felt in the surrounding tissues 
to be about the size of a pea ; it remained for a long time, but at 
length disappeared, leaving behind a coppery -red blotch of the 
same color, as the cicatrices on the legs ; this spot still remained in 
the early part of June, 1852. 

We here find that the first inoculation on the thighs failed. At 
a subsequent period, both arms were inoculated, but on one only 
were any effects produced. Had we been satisfied with a single 
inoculation, and u the second inoculation had not been made on 
the arms, it might have been maintained, with some show of rea- 
son, that he was no longer susceptible to the influence of syphilis. 
Again, this case shows the necessity before forming a decided 
opinion, of repeating the experiment. It will be remarked that 
the blistered surfaces were only twice dressed with the charpie 
moistened with pus. The other dressings consisted of simple 
cerate. 

Second attach of Syphilis. — We know that exostosis has been 
placed completely among the last of the accidents of constitutional 
syphilis, that is the most classical expression of the tertiary state, 
after which, it is asserted, there can be no new attack of the dis* 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 44} 

ease. Now, the case just related, furnishes another proof that an 
individual may have the second attack of constitutional syphilis. 
Indeed, we tind that this patient, after several primitive accidents, 
after a superficial cutaneous eruption, for four years, appeared to 
be cured — that is, there was no symptom of syphilis — and then 
came an extostosis of the tibia, an accident reputed tertiary, and 
simultaneously with this, a deep-seated syphilitic eruption. I re- 
collect perfectly well this first disease, and I treated it successfully 
with the iodide of potassium. But, two months afterwards, the 
patient contracted new chancres, which were about two months in 
becoming cicatrized, and two years afterwards he had a blennor- 
rhagia complicated with orchitis. Finally, in 1850, a new syphil- 
itic eruption appeared on the right shoulder, arms, and on the 
abdomen ; at first it presented the squamous form, then it ulcer- 
ated and suppurated profusely ; finally, crusts formed, which were 
surrounded by large red patches. Is this last eruption to be re- 
garded as the effect of the last chancres, or of the blennorrhagia 
with which he was affected in 1848 ? Was it not a new attack of 
syphilis ? I am aware that it will be answered, that it was only a 
return of the eruption with which he had already been affected ; 
but I would remark, 1st, that this relapse occurred somewhat late, 
for it was three years after the former attack ; 2d, that it was more 
superficial than the former, with which the extososis co-existed. 
Indeed, the cicatrices of both still remain, and may be compared ; 
by which it will be found that the last will be more superficial. 
Now, we know that the syphilitic eruptions are more profound as 
they occur late in the disease. Besides, if the last eruption was 
not produced by a second attack of syphilis, then it was a second- 
ary, occurring after a tertiary accident. Bead the following report 
of the progress of the case made by my interne, M. Codet : 

L. Christian, get. 35, glazier, of lymphatic temperament, feeble 
constitution, admitted June 7th, 1852, Ward 12, No. 10. 

In 1839, this patient contracted a chancre on the glans ; he was 
imprudent, and continued cohabiting with women. Soon new 
chancres appeared, and for three or four years he had sores on his 
penis. At the same time, there were vegetations on the prepuce 
and glans. The inguinal glands on both sides became much en- 
larged, but never suppurated. In 1842, he had confirmed syphilis, 
crusts in the hair, syphilitic eruptions which left but superficial 
traces behind ; these accidents disappeared with scarcely _ any 
treatment. Four years afterwards (1846), L. had an exostosis of 
the right tibia ; at the same time, there appeared deep ulcerations 
on the arm, legs, and a small portion of the trunk. The cicatrices 
of these are still quite evident. L., having been admitted to the 
Eopital du Midi (service of M. Yidal), was placed under the influ- 
ence of the iodide of potassium, and left, cured, in about three 
months. Two months after leaving the hospital, he contracted a 
new chancre. The inguinal glands did not enlarge, according to 
the patient's statement, and the chancre became cicatrized, in the 
course of two months, no other dressings having been applied 
than diluted Goulard's extract. 



y_2 VIDAL ON VENEREAL DISEASES. 

Two years later (1848), lie had a blermorrliagia, accompanied 
with orchitis on the right side. This was cured. The patient 
discovered nothing more until 1850. At this time, there appeared 
a broad, red, slightly-elevated patch, on both shoulders. The 
epidermis soon became detached in the form of scales ; the skin 
was red beneath, new scales formed, and in turn separated. Some 
months afterwards, the patches presenting an analogous desqua- 
mation appeared on the internal surface of the arm (on a level 
with the elbow) and the lower part of the abdomen (on the right 
side) ; these slowly increased for two years, and in the early part 
of the year 1852, a copious suppuration was established on their 
surface. The patient was treated by M. Gribert. The suppura- 
tion rapidly diminished ; and thick crusts formed on the ulcers. 
The patient remained in this condition for some time, and on the 
7th of June entered the Hopital du Midi, service of M. Vidal. His 
constitution seemed only slightly debilitated. The cervical glands 
were nearly natural, the inguinal slightly enlarged. On the 
points mentioned were ulcerations, some of which (on the shoul- 
ders) were nearly twice as large as the hand ; they involved the 
skin ; their surface was covered, at certain points, with thick, red- 
dish, and brown crusts. The surrounding parts were of a charac- 
teristic redness. 

On the 8th of June, the iodide of potassium was prescribed, 
half a drachm to be taken daily. On the 13th, the coppery hue 
and the suppuration had already begun to diminish. This effect 
of the medicine continued for some days. On the 15th, some 
crusts separated ; suppuration almost ceased. 

June 20th. There were only some additional crusts, no more 
suppuration. Large plasters of Vigo were applied to all the 
points involved in the eruption. Under this treatment, the erup- 
tions were promptly affected. 

25th. All the crusts had separated ; there remain only red cica- 
trices on a surface still humid. 

30th. Patient is cured. The parts which were the seat of the 
eruption are now covered with dark red stains. 

Let us pass to the treatment of exostosis. It does not differ 
from that of periostosis, already described. As to the internal 
treatment, we should, as far as possible, resort to the use of the 
iodide of potassium. There is less to be expected from local, 
operative measures, in other words, from the local abstraction of 
blood, blisters, incisions, &c, as, in these cases, a new bone has 
formed, and such superficial measures can, therefore, be of no 
avail ; but we must resort to trephining, resections, and amputa- 
tions, on which, however, we cannot decide until the exostosis, by 
its connections and magnitude, compromises very important func- 
tions, or the life of the patient. These operations are described in 
the works on surgery, to which I would refer the reader. How- 
ever, I must here inculcate certain precepts which are especially 
applicable to resections and exostoses. 

There are cases where the tumor is quite prominent, and ap- 
pears to be pediculated ; we should then make two semi-elliptical 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 443 

incisions, by which its base, the pedicle, is exposed, and with a 
saw we may remove the tumor. The same incisions should be 
employed when the tumor has a broad base, and when there is an 
alteration of the surrounding soft parts, which should then be 
removed with the tumor. But, in the majority of cases, the cru- 
cial incision is to be preferred, for we thus obtain four flaps, the 
methodical dissection of which greatly enlarges the field of opera- 
tion, and facilitates the movements of the saws. These instruments 
should vary according to the form, development, and position of 
the exostoses. In some cases, we require a saw with a flexible 
blade, in others a straight and narrow saw mounted on a handle, 
or we may employ a circular saw. This may be the osteotome 
of M. Heine, which is a chain saw, moving on the edge of a large 
blade. We may be compelled to resort to the gouge and chisel ; 
the part to be operated on should then be firmly fixed, to guard 
against concussions, and these instruments should be made to act 
very obliquely, so that they may act as much as possible as cut- 
ting instruments. The rasp and bone-nippers may be used to fin- 
ish the operation. In some instances we may be obliged to resort 
to the actual cautery, before it can be terminated. 

"When a tumor is very voluminous, we may, so to speak, 
remove it piece-meal ; we divide it into several portions, which are 
afterwards to be separately attacked at several sittings. This would 
be an application of the successive operations (operations en plusieurs 
temps) which I have elsewhere advocated. In cases of epiphytal 
exostosis, it has been proposed to trust the second stage of the 
operation to nature. In the first place, the periosteum covering 
the tumor is to be incised, after it has been denuded as much as 
possible ; the exostosis is then in a condition similar to that of a 
sequestrum, the complete elimination of which is to be confided to 
the efforts of nature. Although an advocate of successive opera- 
tions, I am of the opinion that in these cases the whole should be 
removed at the first operation, unless it is likely to be so protracted 
as to endanger the life of the patient. 

IV.—CARIES AND NECROSIS. 

I regard ulceration and gangrene as the same lesion, for, in both 
cases there is mortification ; in ulceration it is molecular ; whilst 
in gangrene it is by small portions (parcellaire). As there is a 
striking analogy between the two forms of mortification of the soft 
parts, and the osseous lesions called caries and necrosis 1 I shall here 
apply the same principle, and consider the two last affections as 
two forms of the mortification of bone. Those opposed to this 
view of the subject must admit, at least, that caries and necrosis 
often coincide, especially when of syphilitic origin. 

Syphilitic necrosis and caries are often a direct consequence of 
ostitis and of exostosis, which, in this manner,, may be destroyed. 
I have therefore advanced two steps in the inquiry, by the previ- 
ous consideration of inflammations of bone, and of osseous tumors. 
We have now to glance at the various portions of the skeleton 



444 VIDAL ON VENEREAL DISEASES. 

winch may become affected with caries or necrosis, and to consider 
the effects, the accidents which these lesions may determine, and 
the modifications which, according to their position, they may 
undergo. I will commence with the bones of the cranium. 

It is particularly in these cases that we observe the combination 
of caries and necrosis. It is unfortunate that in this situation, that 
the efforts of nature are so feeble in the reparation of the ravages 
committed by syphilis, even when the cause no longer exists. We 
find, indeed, that in necrosis of the bones of the cranium, the 
reparative action observed in other portions of the skeleton does 
not generally precede or follow these lesions, and yet there is 
nothing in the structure of the dura mater which seems opposed to 
ossification, calcareous formations being in fact of frequent occur- 
rence on this membrane. 

Should both tables of the skull become necrosed, as represented 
in fig. 140, of the 2d volume of my Pathologie externe, the case is 
one of a very serious character, and complete reparation is almost 
impossible. If a single table only be affected, that which remains 
suffices to establish the process of reparation ; generally it is the 
external table that becomes necrosed. Then we have the sensible 
and insensible exfoliations of which writers speak. 

A necrosis of the cranium always produces more or less irritation 
in the vicinity of the brain. When the subject is in ordinary 
health, this irritation is limited to the focus of the mortification ; 
but indisposition, even when slight, may increase it, causing it to 
extend and to give rise to an encephalitis. I have seen a woman 
succumb, who for a long time had been affected with a necrosis of 
the frontal bone ; the sequestrum was left to be separated by the 
efforts of nature, although it was movable ; this woman was seized 
with a fit of indigestion, during which the membranes of the brain 
became attacked with an inflammation that terminated fatally. In 
such a case the use of the trephine is indicated; this operation 
should be performed when the disease has been of long standing, 
and when the effect of the general treatment affords us grounds 
for believing that the affection has become localized. Therefore, 
that we may not place too much confidence in the efforts of nature, 
let us endeavor to distinguish the cases and localities in which we 
may properly rely on these forces, and in which surgical interfer- 
ence should be preferred. If in many cases of necrosis of the 
bones of the extremities Ave should not trephine, does it follow that 
the same rule should govern us when the disease involves the 
cranium ? Certainly not. In necrosis of the extremity we have 
to dread only the exhaustion produced by the protracted suppura- 
tion, whilst in the cranium the patient is constantly liable to an 
attack of encephalitis, which may be aroused, as already stated, by 
the least indisposition. 

In September, 1840, a woman died at the Lourcine; in her case 
the whole frontal, and part of the parietal bones, were affected with 
necrosis. Yet this woman did not suffer from the disease ; but, 
during the prevalence of an epidemic she was attacked with ery- 
sipelas, which destroyed her. Her cranium presented a singular 



AFFECTIONS OF THE BONES AND PERIOSTEUM. 445 

appearance : 1st. Simple erosion of the external table ; 2d. De- 
struction of the entire thickness of this table ; 3d. Also of the 
diploe ; and finally perforation. It is remarkable that the diploe 
-was the only part in which reparation had commenced. This 
woman always declared that she had never had the venereal dis- 
ease. When she came under my care her genital organs were 
sound ; but the bones may become diseased long after the primi- 
tive accidents have disappeared. 

Caries and necrosis are rarely met with deep in the orbital 
cavity ; when it is observed here, it is generally from the exten- 
sion of similar lesions in other bones of the cranium. One of the 
consequences of the inflammatory tumefaction characterizing the 
commencement of these affections, is a compression of the optic 
nerve. Surgical interference is here both difficult and dangerous. 
Caries or necrosis may attack the small bones of the ear, and pro- 
duce incurable deafness. In the commencement, when the pains 
are intense, and even at a more advanced period, it is difficult to 
determine what is the malady which we have to encounter. It is 
only by the concomitant symptoms, especially their connection 
with those of disease of other parts of the skeleton, that the diag- 
nosis can be established. Thus, if there exist an exostosis, a ne- 
crosis or apparent caries, if in particular there is caries of the mas- 
toid process conjoined with the symptoms of disease of the inter- 
nal ear, it is very probable that the impaired hearing is due to a 
similar affection of the small bones of the ear. Surgery, in such 
cases, is impotent. The bones and cartilages of the nose may be 
the seat of these lesions. If the nasal bones become attacked with 
caries or necrosis, one of the first symptoms is pain in the part, 
followed by swelling on one side, the color of the skin, at first, 
generally remaining unchanged ; it has rather a puffy feel. The 
skin afterwards becomes red ; by pressing on the nose we discover 
that its framework is less resisting, and that we occasionally pro- 
duce a crepitus. Matter, more or less purulent, issues when the 
patient blows his nose, and at length, small fragments of bone are 
expelled with this matter ; the skin, which on the dorsum of the 
nose is red, becomes more inflamed, and sometimes a small abscess 
is formed, which opens spontaneously ; a fistulous opening exists 
for some time. It is generally at that point where the mucous 
membrane is inflamed, more or less thickened and perforated, that 
the osseous fragments are detached. After they have been ex- 
pelled, the skin sinks in proportion to the extent of the loss of 
substance ; the nose remains more or less depressed, with or with- 
out a cicatrix, as there may or may not have existed previous in- 
flammation or subcutaneous suppuration. If both bones have 
been simultaneously affected, the depression of the skin is greater 
and the deformity more decided. Should there have been a lesion 
of the lateral cartilages, of those of the alas of the nose, septum, 
sub-septum, and the osseous plates entering into the composition 
of the nose, the deformity will be still more considerable. In all 
these cases, the skin may have retained its integrity, but when the 
affection has commenced under the form of the syphilitic tuber- 



446 YIDAL ON VENEREAL DISEASES. 

cular eruption accompanied with, ulceration, the destruction of 
the skin leaving a part of the interior of the nasal cavity exposed, 
the deformity is frightful, and can be repaired only by a rhino* 
plastic operation^ 

The diagnosis is obscure, only when the nasal affection is deep- 
seated. But the sanious, fetid suppuration, and the discharge of 
fragments of bone, soon render the nature of the disease quite 
evident. It is particularly in cases where the posterior part of the 
septum is necrosed, carious, and destroyed, that the voice becomes 
seriously deranged. 

The surgeon should watch his opportunity for extracting the 
sequestra; these, acting as foreign bodies, may maintain a sup- 
puration that shall exhaust the patient's strength. Therefore, 
with dressing or dissecting forceps, he should occasionally attempt 
their removal. He need not hesitate to make incisions on the 
dorsum of the nose, when he can feel the crepitus already men- 
tioned. 

Necrosis, that is, the mortification of important osseous struc- 
tures, may often involve the palatine vault. After a fixed but or- 
dinarily acute pain, has existed for awhile in the palatine region, 
there supervenes a violet-red, fungous-like tumefaction of the mu- 
cous membrane covering the affected bones ; then, a sanious pus 
which sometimes renders the mouth offensive, issues through an 
opening caused by the progress of the disease in this small tumor. 
A portion of bone becomes detached leaving an opening, causing 
a communication between the buccal and the nasal cavities. If 
this loss of substance is not too great, it may become completely 
closed by granulation. But more frequently it remains, though 
it is sometimes almost imperceptible. When the loss of substance 
is more considerable, after the edges have been approximated as 
much as possible by the reparative process, these borders present 
a firm cicatrix, resulting from the adhesion of the soft parts to the 
circumference of the osseous plate, and distinctly circumscribing 
the fistulous opening, which is circular, oval, or irregular. The 
patient then suffers all the unpleasant consequences resulting from 
this unnatural communication, and an obturator is the only means 
that can afford relief. 

I have very frequently observed necrosis of the superior maxil- 
lary bone ; in three cases I early removed the sequestrum, which 
I always found resting on that part of the alveolar process corre- 
sponding with canine and the smaller molar teeth. 

Necrosis of the inferior is generally considered of more common 
occurrence than that of the superior maxillary bone. I have met 
with but one case of it at the liaison de Sante of the faubourg St. 
Denis ; the sequestrum comprised nearly the entire body of the 
bone, which I removed in the presence of M. Morel. 

The cartilages and bones of the larynx may be the seat of ne- 
crosis, and the dead portions may be expelled in the efforts to 
expectorate. Here it is of immense importance to remove the 
sequestra early in the disease ; for they act as foreign substances, 
and maintain an irritation and suppuration, and in many cases 



AFFECTIONS OF THE VISCERA. 447 

may expose the patient to the dangers of a laryngeal phthisis, 
which then actually exists. 

The bones of the vertebras most frequently affected with caries 
and necrosis, are those opposite to the pharjmx ; syphilitic caries, 
involving different portions of the spinal column, especially the 
lumbar region, have been known to produce abscesses by conges- 
tion. M. Baumes remarks that they have occurred when the 
caries affected the lateral or posterior surface, and that when it is 
seated in the anterior portion, an angular curvature is produced by 
the sinking of the bodies of the vertebra. 

In the category of the causes of white swellings of the joints, 
the syphilitic diathesis is always included ; but the diagnosis of a 
syphilitic white swelling is still to be made ; the nocturnal exacer- 
bation is the only symptom that can be regarded as characteristic ! 
The pathological anatomy itself of a syphilitic diseased joint is yet, 
and I think will long remain to be made, for those possessing 
truly this character are extremely rare. 

I have not referred to the internal treatment of caries and necro- 
sis in these cases ; it is the same already frequently. mentioned in 
this article, the iodide of potassium forming the basis of the whole. 
Still, as in some instances the patient may have used this medicine 
for a long time, and the bones may be profoundly affected, it will 
be well in such cases to try iron alone, or combined with iodine. 
I have prescribed ferruginous pills, and those of the proto-iodide 
of iron, and these have sometimes succeeded when the caries have 
been profound, and had reduced the patient to a state of extreme 
cachexy. We may here also administer cod-liver oil, or the 
iodureted oil, according to the formula of M. Personne, pharma- 
cien at the Hojoital du Midi. 

But the surgeon should closely watch the progress of the dis- 
ease, so as to embrace the earliest opportunity of removing the 
sequestrum, or the carious portion of bone. The service thus 
rendered to the patient cannot be too highly appreciated ; for fre- 
quently the syphilitic virus, the primary cause of the disease, no 
longer exists, the effects only remaining, which, in turn, may pro- 
duce serious consequences, such as exhaustion of the strength of 
the patient. 

SECTION IX. 

AFFECTIONS OF THE VISCERA. 

Since the venereal disease has been properly investigated, it has 
been admitted that the syphilitic virus may infect the blood and 
other fluids of the body ; the special lesions of the tissues and or- 
gans, and more especially those of the viscera now under consid- 
eration, have also been recognized. At one period, indeed, syph- 
ilis figured in the whole catalogue of diseases ; it was connected 
with them all. This exaggeration was followed by another, and 
of an opposite kind, denying the existence of syphilitic affections 
of the viscera. The advocates of this doctrine were not sparing in 



448 VIDAL 02s T VENEREAL DISEASES. 

their sarcasms against those who entertained a different belief. 
At the present day, the ancient doctrine seems likely to be revived, 
but it makes slow progress, as yet it has only probabilities in its 
support.- As the history of syphilitic affections of the viscera has 
yet to be made, I shall attempt to give merely an outline of the 
subject. 

In the first place, it is unnecessary to force analogy in order to 
admit syphilis as an occasional cause of certain affections, of which 
the germ or predisposition already exists. Direct observation 
here confirms analogy ; indeed, more than one latent phthisis has 
been aroused under the influence of syphilis. Of this there can 
be no question. It is not in the thoracic viscera alone that the 
tubercular element has been called into action by this influence, 
but it has likewise been the cause of similar affections of the lym- 
phatic system, and more than one scrofulous bubo has been the 
result of this agency. 

But what is most difficult to be established is the existence of 
visceral lesions essentially syphilitic, having anatomical characters 
and a symptomatology proving their specific nature. In analyz- 
ing the lesions' of the internal organs which have been observed, 
I will prove what I have here asserted, and at the same time fur- 
nish the young practitioner, anxious to elucidate this point, with 
the few materials, or, more properly speaking, the few notes which 
I have been able to collect. 



I.— CEREBRAL AFFECTIONS. 

Tubercles resembling the deep-seated tubercles of the cellular 
tissue (gummata) have been observed in the brain. But can these 
tubercles be distinguished anatomically from other tubercles, from 
those commonly described in works on pathology, and which pro- 
duce such fatal havoc when seated in the lungs ? The same ob- 
scurity prevails on the symptomatology, for the lesions of sensation, 
motion, and intellect, may all result from a cerebral affection en- 
tirely independent of syphilis. Still further, the syphilitic diathe- 
sis may produce other effects on the cranium, which may be con- 
founded with the gummata of the brain, as, for example, tumors 
of the dura mater, and exostoses of the cranium. And here we 
can derive no assistance from treatment in clearing up our diagnosis, 
for the cranial, like the cerebral lesion, may be equally modified 
by the same agent, viz., the iodide of potassium ; indeed, under 
the influence of this therapeutic agent, the symptoms and accidents 
produced by both of these affections may be made to disappear. 
The age, antecedents, and concomitant symptoms, may assist the 
practitioner, and conduct him to probabilities approaching to cer- 
tainty. Thus, what is remarkable, I have observed almost simul- 
taneously two cases of serious encephalic disease, attended with 
symptoms of cerebral disturbance. 

By means which I am about to mention, I was enabled to estab- 
lish the probability of the syphilitic nature of both affections, and 



AFFECTIONS OF THE VISCERA. 449 

of their seat. Both, patients were young, being scarcely thirty 
years of age. The first had been attended by a physician who 
became confined to his bed. The young man was attacked with 
symptoms of apoplexy. One of my colleagues, M. A. Kobert,* was 
called, and not knowing the previous history of the case, treated 
the patient for ordinary apoplexy. The most alarming symptoms 
having been removed, the intellectual faculties remained impaired, 
memory, especially, being at times lost. My colleague was not 
aware that this young man had had an indurated chancre, and 
syphilitic eruptions on the skin, and the patient, who had concealed 
his condition from his family and friends, was not forward in 
making him a confidant. Finally a consultation was held ; as I 
had treated the young man for his syphilitic attack, I was called. 
The iodide of potassium was prescribed in large doses ; one and a 
quarter drachms were given daily. The intellectual faculties were 
rapidly re-established, and the patient suffered nothing more from 
his attack. Therefore, taking into consideration the age of the 
patient, the syphilitic antecedents, and the rapid effects of the iodide 
of potassium, I came to the conclusion that this was not a case of 
ordinary apoplexy, but a syphilitic affection of the head. "Were I 
to venture on a further expression of my opinion of the nature of 
this case, I should say, that it was not an osseous lesion, an exos- 
tosis of the cranium, but an affection of the brain itself, the com- 
mencement of plastic deposition, for the effects of an exostosis are 
not so speedily removed. I acknowledge, however, that this is 
mere conjecture, and it will have been remarked, that the skilful 
surgeon first in attendance discovered nothing peculiar in the first 
symptoms, or which might indicate a specific affection. Here the 
knowledge of the previous history of the case, and of the effects of 
the iodide of potassium, were wanting in establishing the diagnosis. 
The second patient lived in the suburbs. He had hemiplegia, 
which was slowly developed. The antecedents in his case were 
chancre, cutaneous eruptions, and syphilitic sarcocele. I had pre- 
viously treated these affections. Being aware, therefore, of the 
previous history of the case, and considering, too, that the patient 
was quite young to be attacked with ordinary apoplexy, I thought 
it exceedingly probable that this was a syphilitic encephalic affection. 
I went so far even as to presume upon the seat of the disease. The 
slow development of the. paralysis, the fact that there existed an 
exostosis of the lower jaw, led me to diagnose a cranial exostosis. 
In this I was confirmed by the time required to cure the patient 
(a year), the same that was required to remove the exostosis of the 
lower jaw. I repeat, that we are here dealing in probabilities, but 
in probabilities possessing a value which the most attentive exami- 
nation of facts in medicine cannot always impart. Whatever may 
be the scientific bearing of these two cases, or theoretical interpre- 
tation, they remain two instances of cure worthy of the practi- 
tioner's attention. 

* On account of the standing of the patient, I am compelled to omit the name 
of the family physician, who, besides, will readily recognize whom I nieau. 

29 



450 VIDAL 03" VENEREAL DISEASES. 

[Dr. Budd lias reported in the Lond. Med. Gazette, for May, 1842, 
three cases in which apoplexy occurred in the advanced stages of 
syphilis. These patients had been for some time affected with 
periostitis, and two of them had had a syphilitic eruption (rupia). 
Dr. B. says, it may admit of question, whether the apoplexy re- 
sulted from the immediate action of the syphilitic virus on the 
♦brain, or whether it was consequent on syphilitic inflammation of 
the bones of the head. In connection with this subject, we refer, 
with much pleasure, to the admirable papers by Dr. John Watson, 
of the New York Hospital, " On some of the Remote Effects of Syphi- 
lis" which were published in the first and fifth volumes of the New 
York Journal of Medicine and the Collateral Sciences, (1843, 1845.) Dr. 
W. has reported some eight cases of hemiplegia and epilepsy, result- 
ing from syphilitic disease of the cranial bones and envelopes, and 
tubercular deposits in the substance of the brain itself In one of 
these cases, the patient, contrary to the advice of Dr. W., was tre- 
phined, his cerebral symptoms having been attributed to a blow 
on the head received some two years previously. He died some 
months afterwards ; extensive changes were found to have taken 
place within the brain and its envelopes, and the deposits of yel- 
lowish dirty- white color in the former, Dr. W. regarded as syphilitic, 
tubercle. The cases above mentioned, together with those men- 
tioned by Mr. Inman (Lond. Med. Gazette, July, 1843), disprove the 
assertion of Sir Astley Cooper, that the brain, abdominal, and 
thoracic viscera, are incapable of being infected by the syphilitic 
poison. (On the Testis, 2d Lond. Ed., p. 166.) We regard Dr. 
Watson's contributions by far the most valuable yet made on this 
subject, for his remarks are founded on the autopsies made by 
himself.— a. C. B.] 

II.— HEPATIC AFFECTIONS. 

Syphilitic affections of the liver in the infant have been carefully 
investigated by M. Grubler. He has found, as the anatomical lesion, 
a fibro-plastic induration, which may be partial or general. When 
I come to treat of infantile syphilis I shall carefully describe this 
double lesion. 

In the Iconographie of M. Eicord (pi. 30) is represented a partial 
induration, a very remarkable nucleus in the liver of an adult. 
The subject, who had died from a deep-seated affection of the 
larynx, presented serious anatomical alterations of this organ. 
The liver, of medium size, was of the ordinary color and con- 
' sistence ; on the convex surface of its lobe was found a tumor, 
perfectly round, as large as a walnut, somewhat prominent, and 
involving nearly the whole substance of the organ. This tumor, 
consisting of two parts, appeared to be surrounded by a kind of 
cyst ; it was composed of a hard, dense, very homogeneous tissue, 
crackling a little under the knife, and offering no traces of vascu- 
larity. It seemed to present a striking analogy with certain tumors 
of the cellular tissue, which are frequently observed in tertiary 
.syphilis. As to the symptomatology, it is stated in the report: 



AFFECTIONS OF THE VISCERA. 45 1 

" For some months the patient had suffered from cholicky pains, 
which, from his description, resembled those produced by biliary 
calculi. Further, he had had several attacks of jaundice, traces of 
which were still apparent on his admission to the Maison de Xante." 
It will be seen that there are no peculiar symptoms of the disease, 
and that they might have been referred to several different affec- 
tions of the organ. Besides, in examining the colored plate repre- 
senting the above tumor, it is not difficult to recognize a form of 
cirrhosis denominated by Laennec, cirrhosis in masses. Therefore, 
the history of syphilitic disease is yet far from being complete ; it 
has not even been commenced. 

III.— CARDIAC AFFECTIONS. 

Syphilitic affections of the heart are almost unknown. In the 
Iconographie of M. Eicord, however, is the representation of a lesion 
which this physician regarded as belonging to the class of tumors 
called gummata. The subject had had repeated attacks of chancre 
on the penis, accompanied with vegetations ; these were followed 
by mucous tubercles about the anus. Finally, groups of tubercles, 
which ulcerated, appeared on various portions of the skin. He 
was treated with the proto-iodide of mercury and the iodide of potas- 
sium, for eleven days, when, in going to stool, at seven o'clock in 
the morning, he was suddenly attacked with giddiness ; he returned 
to his ward, threw himself on the bed, and expired in less than five 
minutes. Previous to this fatal event, with the exception of the 
accidents mentioned, "there were no symptoms which could have 
led to the suspicion of any deep-seated affection." 

" Before death, the face of the patient became of a violet color, 
after which it turned pale ; he had to utter these words only : ' I 
feel very sick;' (Je me sens tres mat.) 

' " The autopsy, made twenty -four hours after death, disclosed 
the following appearances : 

" With the exception of the heart and lungs, all the viscera were 
sound, but presented very strong marks of congestion. The heart 
was hypertrophied, its cavities were filled with clots of blood, of 
slight consistence. The endocardium of the right ventricle exceed- 
ed two-fifths of a line in thickness ; it was of a dull white color, 
and of fibrous consistence. 

" The endocardium of the left ventricle presented nothing abnor- 
mal; but, in that portion of the cavity next the apex, we found an 
adherent layer of very friable blood, beneath which was a kind of 
apoplectic clot, which occupied the whole thickness of the wall of 
the ventricle. The blood was intimately united with the muscular 
substance, the normal consistence of which was destroyed, by 
which we were led to infer that the affection was not the result of 
ah accident; the pericardium on a level with this clot Avas puffed 
up, and thickened. The apex of the heart was covered externally 
by a false membrane, one and one-fifth of a line in thickness. _ The 
walls of the ventricles at several points presented a. tubcrculiibnn 
alteration consisting of a firm yellow matter, cracking beneath the 



452 YIDAL ON VENEREAL DISEASES. 

knife, not vascular, of a schirrous consistence at certain points, and 
at others, of an aspect analogous to that of a tubercular matter in 
process of softening. In a word, we found here the character of the 
syphilitic node or tubercle, tertiary accidents which are frequently 
observed in the subcutaneous or sub -mucous cellular tissue. 

" No muscular fibres were found compressed by all these morbid 
productions, for the degenerated mass was composed of the mus- 
cular fibre itself. Besides, we were able to follow the evolution of 
this transformation, which seemed to have commenced by a union 
of the blood with the fleshy fibre. And, indeed, in this condition 
the lesion still existed at several points. In others, it presented a 
yellow color, and had reached, centrally, a greater development. 
But at the circumference, the combination of the blood with the 
fleshy fibre which took place in the commencement of the affec- 
tion, was still evident. The lungs, perfectly sound at their apex, 
presented at their base several tuberculiform transformations as 
large as a pea, and precisely similar to those found in the heart."* 

My former friend, Professor Forget, is disposed to regard these 
supposed syphilitic vegetations of the heart as the offspring of the 
imagination, as well as most of the other syphilitic lesions which 
it has been pretended have been found in this organ.f 



IV._PULM0NAKY AFFECTIONS. 

The lungs and bronchi have always been regarded as especially 
liable to syphilitic lesions. M. Gr. S. Lagneau, son of the vener- 
able author of the Traite des maladies syphilitiques, has collected all 
the recorded facts which relate to these affections, and in a reliable 
work has attempted to show that syphilis affects the lungs and 
bronchia : 

1st. By producing alterations essentially syphilitic, that is, ac- 
knowledging syphilis as the exciting cause. These alterations he 
divides into two classes, first, affections generally slight, compris- 
ing acute inflammation of the bronchia and the parenchyma of the 
lungs, intermittent bronchial inflammation, or asthma, and chronic 
bronchitis. Secondly, we have more serious disorders, by most 
authors termed phthisis, comprehending chronic bronchitis, with 
ulceration, chronic inflammation of the parenchyma and lymphatic 
glands, pleuritis, syphilitic tuberculization, or the formation of the 
gummy tumors (gummata). 

2d. It may rouse into action tubercles which had existed before 
the syphilitic infections, or manifest its effects by exciting the evo- 
lution of tubercles, the progress of which it has a tendency to 
accelerate. 

According to M. Gr. S. Lagneau, every organic lesion found in 
individuals affected with syphilitic pulmonary disease may be re- 
ferred to one of these two divisions. Among the anatom-patho- 

* Vid. report of the case by M. G-abalda, in the Iconograjphie of M. Ricord, 
f Prea's analytique des maladies du cceur, p. 261. 



AFFECTIONS OF THE VISCERA. 453 

logical conditions peculiar to the first, that is, the lesions essentially 
syphilitic, the author specifies the following : 

Chronic Ulcerative Inflammation. — This consists in small, isolated 
or continent ulcerations, united, occupying the whole or a part of 
the bronchi, becoming sometimes very numerous in the minute 
ramifications of the bronchi, which are then filled with purulent 
matter. 

Inflammation and Ulceration of the Lymphatic Glands, and of the 
Pulmonary Parenchyma. — Inflammation of the pulmonary tissue 
presents numerous degrees, from the simple congestion to hepati- 
zation, and the formation of purulent foci. These ulcers, and pur- 
ulent collections, form especially in the middle lobe ; the cavity 
containing the pus is surrounded neither by a membrane, nor in- 
duration; sometimes the lung appears externally sound, and no 
exudation is observed. In the young infant, we find also abscesses, 
indurations, and extensive suppurations ; in the recently -born infant 
we meet with indurated nuclei, impermeable to the air, friable, 
hepatized, occupying, by preference, the apex of the lung. These 
nuclei, of different dimensions, generally numerous, become yellow, 
compact, a Cavity forms in their centre, it present walls of greater 
or less thickness, infiltrated with pus ; it is filled by a yellow, sero- 
purulent fluid. The microscope detects in this fluid the presence 
of pus ; the surface of the lungs is bosselated, arising from these 
purulent collections, adhesions exist between the pleural surfaces, 
and sometimes the parenchyma is compact, yellow, and friable. 
At other times the virus exerts its influence particularly on the 
pulmonary, lymphatic ganglia, which become engorged, indurated, 
and terminate in suppuration. These observations apply particu- 
larly to the lesions recently observed by M. Depaul, and which I 
shall describe more fully when I treat of infantile syphilis. 

Pleuritis and Effusion. — The pleura may become raised at various 
points in the form of blisters, in patches of from two-thirds of an 
inch to two inches in diameter, by the effusion of a thick, yellow 
mellicerous fluid ; sometimes also there may be a more extensive 
effusion. 

The gummy tumors {deep-seated syphilitic tubercles), involve the 
parenchyma ; sometimes they are very numerous ; and terminate 
slowly in suppuration. In order to establish their anatom-pa- 
thological condition, M. Lagneau copies from Astruc, Schroeder, 
and Dr. McCarthy. Among other things, he inserts the following 
passage from an article written by M. Foucart, after a lecture of 
M. Kicord: "According to this physician, one of the situations 
in which the gummy tumors are developed more frequently than 
is generally supposed, and a knowledge of the existence of which 
is most important, is the pulmonary tissue." For several years, 
he states, we have had quite a number of autopsies which led us 
to the conclusion that there are pulmonary lesions which must of 
necessity be referred to syphilitic tubercles. It pursues the same 
course here as in other parts of the body, it is the same form, the 
same development, the same fatal termination in suppuration. 
The patients expectorate pus as in the most advanced stages of 



454 VIDAL OX VENEREAL DISEASES. 

pulmonary tubercles ; they become emaciated, feeble, and death 
soon follows.* 

This extract is from a lecture delivered by Eicord in 1845. In 
his Iconographie, he has been more precise in his anatomy, and less 
explicit as regards the nature of the pulmonary affections, for he 
speaks in presence of the cadaver ; for example, in describing the 
autopsy of a venereal patient, it is stated in his work; "Violet- 
colored spots were found, beneath which were indurated nuclei, 
which, at first view, resembled those found in the lungs of those 
who have died from pneumonia, the result of purulent absorption. 
These nuclei when incised, were found to contain no pus, but pre- 
sented a deep red, friable tissue. In the left lung were found five 
small cavities half filled with a whitish viscous matter, together 
with a grayish pultaceous matter which appeared to proceed from 
the walls of the cavity, which were soft and of a grayish color. 
The largest of these cavities would have contained a small nut. 
They were situated near to each other at the lower portion and 
and near the external border of the lung."f The report is followed 
by the following reflections : " These alterations leave us in un- 
certainty as regards their nature, and it would be drmcult to say 
whether they are syphilitic, whether these cavities contained terti- 
ary tubercles, which became softened and expelled, or whether 
they were the results of purulent absorption." M. Eicord here 
notices another fact ; J there can be no doubt that a very considerable 
number of autopsies are required to establish the fact, that these pul- 
monary lesions are due to syphilitic tubercles. 

It is to be regretted that M. Gr. Lagneau did not have under his 
eyes the version given in the Iconographie, which singularly modi- 
fies the report in the Gazette des Hopitaux. Doubtless after such 
a contrast, M. Lagneau would have been more reluctant to admit 
these pulmonary lesions to be essentially syphilitic. 

M. Lagneau enters fully into the symptomatology of these affec- 
tions. But, M. Cazenave, who had reviewed his work, remarks, 
that notwithstanding his attempt to frame a table of symptoms, it 
will still be very difficult, even after the most careful study, to 
select from the group those peculiar to acute or chronic bron- 
chitis, ulcerated or non-ulcerated, to asthma, pleurisy, chronic 
pneumonia, and the tuberculization essentially syphilitic. In the 
majority of cases, likewise, accident or some unexpected revelation 
has led to the formation of a diagnosis rather than any particular 
symptomatology. § 

It was accident, as stated by M. Cazenave, that enabled me to 
effect a cure in a patient supposed to be laboring under the last 
stages of phthisis. This patient kept a lodging-house near the 
porie St. Martin. He had been treated, and in common language, 

* Yid. Gazette des Hopitaux, 1845, t. vii., p. 610. Eeprint of a lecture of M. Eicord 
on tertiary accidents. 

f Vid. Zconographie. 

% Only, it is stated in the report of the autopsy already quoted, that in a case 
of syphilitic disease of the heart, the lungs presented analogous lesions. 

§ Amiales des maladies de la peau et de la syphilis, Jan. 1852. 



AFFECTIONS OF THE VISCERA. 455 

condemned by a distinguished member of the Academy of Medi- 
cine. This patient was brought to me by a friend, and I was 
about to send him to a physician, when he showed me a tumor on 
the clavicle. This discovery led me to examine him more closely, 
and to inquire for the previous history of the case. He had had 
chancres on the penis four years before the appearance of his pul- 
monary trouble and the tumor on the clavicle. He coughed much, 
especially morning and evening ; he showed me nummular expec- 
toration ; he had night sweats ; his emaciation was extreme ; and 
respiration constantly laborious. I was wrong in not auscultating 
the chest. But I placed the patient on the use of the iodide of 
potassium : at first, in fifteen-grain doses, which was increased to 
one drachm daily. In less than a month, he had improved beyond 
all expectation, and in less than two months he had resumed his 
occupation. At present, six weeks from the commencement of the 
treatment, the patient is in the enjoyment of most excellent health. 

We may reasonably conclude that syphilis, in this case, exerted 
a powerful influence in the production of the pulmonary disease 
which was destroying the patient. But this opinion I was enabled 
to form only from the concomitant symptoms of the clavicular 
tumor, and the antecedents as manifested in the chancres on the 
penis, and the effects of the iodide of potassium. The symptom- 
atology, esjoecially as derived from the physical examination of 
the chest, were wanting, and I should not have been warranted in 
classing this affection among those essentially syphilitic. 

Such facts are, therefore, insufficient to settle the scientific ques- 
tion, But they possess a real value in a practical point of view. 
They teach us to carefully examine the antecedents of the case, 
when there exists chronic pulmonary disease, and not to decide 
upon an anti- venereal treatment, unless the previous history of the 
case leads to the suspicion of a syphilitic infection. The more I 
study the chronic affections of the viscera, those called organic, the 
more firmly persuaded am I that patients are allowed to perish by 
what is regarded as ordinary tubercular disease, from the want of 
an anti-syphilitic treatment. 

The following case, to which M. Lagneau attaches a truly scien- 
tific value, is, in my opinion, but the counterpart of that which I 
have minutely detailed. 

"An actor, get. 46, M., affected with syphilis for more than 
twenty years, presented a periostitis on the anterior surface of the 
left tibia, and suffered from nocturnal pains in all his limbs. With 
these symptoms were combined all the rational signs of the last 
stages of phthisis, and there was every reason to believe that his 
existence would soon be terminated, in the country, whither he 
had been sent to live on ass's milk. When my father was called, 
together with M. Andral, to consult with M. Marc, when the pa- 
tient made a temporary visit to Paris, he presented the_ following 
symptoms : cough, puriform expectoration, sweats, pains in the 
chest, low fever, prostration, marasmus, and hemoptysis; no phys- 
ical signs were discovered on auscultation. The result 01 the 
auscultation was, to place the patient under an anti-syphilitic 



456 YIDAL ON VENEREAL DISEASES. 

treatment, which was carried out under the direction of M. Marc, 
according to the plan of Scatigna — that is, by the daily application 
of half a drachm of the Neapolitan ointment to the axillae, and the 
use of a sudorific tisane with milk. On the thirteenth day of 
the commencement of this treatment, the pains in the chest and 
limbs, the low fever, prostration and tumefaction of the periosteum, 
were already dissipated. After the thirtieth application of tie 
ointment, the patient had regained much of his ordinary embon- 
point, and the cough had ceased ; on the fortieth day the cure was 
complete. The patient devoted himself for some time to his pro- 
fession, singing, and then retired into the province. M. Marc 
has learned that he afterwards died' — of what malady, however, he 
was not informed.* 

The symptomalogy of these pulmonary affections, which M. 
Lagneau regards as essentially syphilitic, not having been made 
either by this author, or by other writers on syphilis, we can ap- 
preciate the difficulties, I might almost say the impossibility of dis- 
tinguishing them from, for example, the tubercular pulmonary 
affections which had previously existed, and which have been 
roused into action by the sj^philitic influence, which has hastened 
their development and the accidents to which they give rise. 

In conclusion I would remark, in regard to the knowledge 
which we possess of the syphilitic affections of the viscera : 1st, 
that analogy confirms their existence; 2d, that this analogy is 
corroborated by certain facts in pathological anatomy ; 3d, that 
certain cures of serious chronic pulmonary affections, with their 
antecedents or concomitant syphilitic symptoms, that these cures, 
being effected by specific treatment after other means have failed, 
do not completely disclose the syphilitic nature of these pulmonary 
affections, but should receive great consideration, especially by 
the practitioner, who, on the least suspicion of the agency of syph- 
ilis in the disease, should resort to specific treatment. 

[The attention of many of the older writers was directed to the 
subject of syphilitic diseases of the lungs, among whom we may 
mention Severinus, Sauvage, Portal, Morgagni, Hoffman, Hewson, 
and Morton ; among the more modern authors we may reckon 
Drs. Graves, Stokes, Byrne, Sims, Munk, and John Watson. Dr. 
Munk has published two papers upon this subject, in the London 
Medical Gazette (vol. ii., new series, pp. 179, 218), which are wor- 
thy of a perusal. We have seen cases of pulmonary disease which, 
there was every reason to suppose, were produced by the action 
of the syphilitic virus, yet it is difficult, if not impossible, to decide 
upon the actual influence of this cause. Dr. John Watson has 
reported a case, where the patient, just before death, was seized 
with hemoptysis, which was so profuse as to carry him off almost 
instantly. In the examination, a ragged, circular ulcer, nearly as 
large as a cent, with dark, purpled edges, was found in the left 
bronchus, just beyond the bifurcation; this had perforated the 
bronchial tube, communicating with a sort of cavity in the cellu- 

* Des maladies pulmonaires causees ou influences par la syphilis, by G-. S. Lagneau. 



AFFECTIONS OF THE VISCERA. 457 

lar tissue outside of the tube, and thence extending to one of the 
left branches of the bronchial artery, into which it had opened. 
There was a second ulcer within the same bronchial tube, about 
one inch and a half or two inches deep, as large as a half-dime 
piece. This had nearly perforated the bronchial tube, and had an 
irregular base, with ragged and uneven edges of the same color as 
the other. Previous to the death of this patient, he had been un- 
der the care of Dr. Buck, in the New York Hospital, for a second- 
ary ulcer over the parotid region, and there were some spots of 
syphilitic rupia in other parts of the body with slight cough. (New 
York Journal of Medicine, July, 1843, p. 57.) — Gr. C. BJ 



PART THIRD, 

INFANTILE SYPHILIS 



The study of infantile syphilis cannot be separated from its 
necessary connections with syphilis in the parent, the condition 
of the nurse, and the early care which it may receive. Besides, it 
is not syphilis in the new-born child only that we have here to 
consider, but frequently that of the embryo, the foetus, &c, &c. 
In the investigation of the causes, I shall examine the influence 
of the parents and the nurse. It is obvious how deeply the family, 
society, and legal medicine are interested in the questions now to 
be discussed, and yet in the most widely-circulated works on ven- 
ereal diseases, this subject has received but little attention! In 
the first place, I shall describe the symptoms and the pathological 
anatomy, thus commencing with what admits of least dispute; 
afterwards, I shall enter into the consideration of the causes, under 
which head are included the influence of the parents and the nurse 
upon the child, and vice versa. Of course, the question of the 
transmissibility of syphilis by the blood, the products of secretion, 
and the consecutive accidents, will here be renewed, and its solu- 
tion in favor of the contagionists no longer admits of doubt. 

Symptoms. — Infants who have suffered from the syphilitic influ- 
ence in utero, are born shrivelled and emaciated ; their flesh is soft, 
skin of an earthy color, flabby and wrinkled, giving them a senile 
appearance. In the language of Doublet, they are "miniatures of 
decrepitude ;" some perish before any evidence of syphilis is 
manifested ; in others, we observe the accidents and symptoms 
which I shall soon describe, and we meet even with vegetations, as 
shown by the several cases reported in the work of Bertin. Such 
facts have therefore been unjustly denied. The majority of chil- 
dren are born with the appearances of the most perfect health. 
Some weeks or months after birth, they present symptoms or acci- 
dents of constitutional syphilis. Bertin remarks, that according 
to his observation, these symptoms or accidents are developed 
from the third to the sixth week ; but he admits that they may 
appear before this period. 

The attention of the nurse is first arrested by the difficulty of 
respiration, and a snuffling noise, especially whilst suckling. This 
is the commencement of the syphilitic coryza. The nose is ob- 
served soon to become red, and tumefied ; the nostrils crack, and 



INFANTILE SYPHILIS. 459 

almost constantly discharge a purulent humor mixed with blood. 
A portion of this fluid, as it becomes dried, forms crusts which 
obstruct the nasal cavities ; the little patient breathes by the 
mouth only, which is constantly more or less open. The lining 
membrane of the nose, of a livid red color, tumefied and softened, 
is often the seat of superficial ulcerations, and bleeds from the 
slightest contact. Eespiration through the nose, at first embar- 
rassed, becomes more difficult ; suction of the breast is at length 
rendered impossible, and if this condition be prolonged, the child 
perishes from inanition. 

When decided inflammation exists, we should use, at first, 
emollient, and afterwards astringent lotions, or cauterization with 
the nitrate of silver. 

M. A. Deville has furnished M. Bouchut an account of four 
cases of infantile syphilis in which coryza existed, and all of these 
children were born of mothers affected with syphilis. Three of 
them presented on their bodies signs of syphilitic infection. 
They were treated with iodide of potassium in doses of from seven 
to fifteen grains a day, under which their condition rapidly im- 
proved. Three were perfectly cured ; the fourth died from an- 
other disease, the small-pox.* 

It is generally admitted by writers that infantile syphilis most 
frequently appears under the pustular form. Bertin, in his spe 
cial treatise, observes : " Pustules were symptoms most commonly 
observed in infantile syphilis during my connection with the vene- 
real hospital." "We generally meet with the mucous tubercle, 
such as I have described in the latter part of the first section of 
this work. In these cases they are found not only in the regions 
already specified, but wherever folds in the skin exist, as for ex- 
ample, on the thighs, buttocks, and in the axillae. Sometimes they 
occur in patches more or less broad, sometimes the tubercular or 
the lenticular form is most strongly marked. In parts where the 
skin becomes heated, these tubercles discharge, even abundantly, 
a matter of an offensive odor, which produces more or less erythe- 
ma or eczema in the vicinity. At other times the tubercles are 
dry, and covered with a kind of scaly layer. 

The mucous membrane is also the seat of* these tubercles which 
then become complicated with cracks or small fissures. Thus, at 
the commissure of the lips, at the side of a tubercle, we observe a 
fissure which has a tendency to heal, but which is overcome by 
the movements required in suction of the breast, which act is at- 
tended with pain. On the tongue, we notice little whitish lenticu- 
lar elevations, as if the nitrate of silver had been applied to its 
surface ; if possible to open the mouth, we observe these white 
spots extending towards the throat and pharynx. The same lesion 
has been supposed to occur in the intestinal canal, and to have 
produced bloody mucous stools. The microscope has detected the 
presence of cryptogamia in the secretions of the lips and mouth. 

The ecthymatous form of pustule is also frequent in infantile 

* Bouchut, Traite pratique des maladies des nouveau.v-ih$, p. S69. 



460 VIDAL ON VENEREAL DISEASES. 






syphilis. "When," says M. Gibert, " we meetwitli a really syph- 
ilitic eruption in the child, it ordinarily assumes the form of ec- 
thyma."* It is observed even on the palms of the hands, and 
the soles of the feet, here replacing the horny squamous syphilitic 
eruption which, at this period of life, is very rare. Impetigo, es- 
pecially facial impetigo, now and then occurs. 

The erythematous form is common; children appear as if 
scalded, particularly wherever the parts are subjected to friction, or 
pressure. The anus, thighs and genital organs often become red 
and sensitive. This condition is then attributed by the nurse to 
teething, even before it is time for the teeth to appear ; they are 
greatly in the habit of using, simply, powders which produce no 
effect. The physician is now consulted. Whatever may be the 
form of the syphilitic eruption, it has a great tendency to ulcerate ; 
these ulcerations are most frequently observed over the sacrum, 
on the nates, and on the heels. 

As I have already stated in speaking of the syphilitic bulla in 
the adult, M. P. Dubois has described a syphilitic pemphigus in 
the new-born child. It is generally acute, and the bullae are as 
large as a pea, rarely as large as a small walnut. They are more 
or less numerous ; more than a hundred have been counted on 
one child ; they are then in close proximity, some of them being 
united at their base. They contain a yellowish, purulent fluid, 
which is sometimes fetid, and even mixed with blood. They may 
occur on all parts of the body. Most generally they are seen on 
the palms of the hands and the soles of the feet. The points of 
the skin on which the bullae are raised, have a violet or blue tinge, 
which contrasts with the rosy hue of the other portions of the 
skin. Sometimes the dermis is eroded, ulcerated, and covered with 
a plastic membranous deposit. These ulcerations, occasionally, 
comprehend the whole thickness of the skin, and suppurate 
abundantly ; their margins are sometimes elevated and rounded, 
and at different points they present the appearance of the last 
stages of ecthyma (P. Dubois). Sometimes we do not at first ob- 
serve spots of the color mentioned ; afterwards the epidermis be- 
comes raised, and the pemphigus is complete. The bulla, once emp- 
tied, the spot is occasionally reproduced as before ; there is a relapse. 

Syphilitic pemphigus may occur in children who were born 
well developed ; most generally, however, it is observed in those 
which are feeble, and prematurely born. In all cases, its appear- 
ance is ominous, as nearly all die who are born with it, or on 
whom it appears after birth. It is not unusual to find children 
which have died in utero bearing traces of this eruption. Pemphi- 
gus is especially grave when complicated with the affections of the 
lungs or thymus gland which I shall presently notice. In speak- 
ing of pemphigus in the adult, I have stated that the syphilitic na- 
ture of pemphigus in the new-born child has been called in ques- 
tion. M. Bouchut endeavors to establish a differential diagnosis be- 
tween specific pemphigus and simple pemphigus. He observes : 

* Manuel des maladies vcneriennes, p. 440. 



INFANTILE SYPHILIS. 461 

" On the one hand, we find the bullae filled with well-formed yel- 
lowish pus, whilst in simple pemphigus they are filled by a clear 
or opaline serous fluid. In the one case, the color of the excoriated 
skin is red and livid ; in the other, it is of a clear rosy hue. In 
the one the skin is eroded and even ulcerated ; in simple pem- 
phigus it is never ulcerated ; in the one case the bullae co-exist with 
syphilitic lesions in the other organs, such as eruptions on the 
skin or mucous membranes, with abscesses scattered through the 
substance of the thymus gland or lungs, with fibro-plastic de- 
generation of the liver, onyxis, &c. In simple pemphigus, on the 
contrary, the bullae constitute the only symptom. In fine, the 
one is with difficulty cured, and only by mercury administered to 
both child and nurse, whilst the other is cured by simple diluents."* 

I would remark that syphilitic pemphigus is not always accom- 
panied with other syphilitic eruptions, and the visceral lesions 
mentioned by M. Bouchut are revealed only by an autopsy. 

Besides the eruptions described and which belong to the super- 
ficial forms, we may also observe tiae deeper seated. Indeed, the 
child is sometimes affected with syphilitic ecthymatous pustules 
similar to those found on the extremities, especially the legs of the 
adult, pustules which are broad, deep, and the ulceration of which 
has perpendicular borders. The child may also present the tuber- 
cular form of eruption with an ulceration as if perforated. But it 
must be admitted these forms are rare. 

[In Dr. Bulkley's elaborate paper on Syphilis in Infants {New York 
Jour, of Med., Oct. 1840, p. 247), he alludes to the modified appear- 
ance of these eruptions and ulcerations as they appear in mulattoes 
and blacks, and relates some interesting cases, showing that in these 
they assume a whitish appearance. The dusky-colored spots on 
the skin were surrounded by whitish circles, " the color of the 
white being lighter, and that of the dark deeper, than the natural 
hue of the skin." In the article from which we quote, Dr. B. states 
that up to that time (1840), he had had under his immediate care 
35 cases of infantile syphilis, and we have recently been assured 
by him, that he has now treated some 60 cases, probably a much 
larger number than has fallen to the share of any American prac- 
titioner. We regret that our limited space prevents us from no- 
ticing this contribution to the subject of Infantile syphilis more 
fully, but we can only refer the reader to the essay itself, assuring 
him that he will here find every point of interest and importance 
connected with it, most ably discussed. — Gr. 0. B.] 

In infantile syphilis we seldom find the bones or their append- 
ages involved. Bertin quotes but the following case : 

" Pierre Gr., set. 35 days, removed from la Maternitc to our de- 
partment on the 1st Jan., 1809, was attacked with a very severe 
blennorrhagic ophthalmia, and tubercular pustules, over nearly 
the whole surface of the body, and a tumor the size of a pigeon's 
egg over the left great trochanter, and a very considerable perios- 
titis on the superior and posterior surfaces of the ulna. The tumor 

* Bouchut, loc. cit. 



462 VIDAL ON VENEREAL DISEASES. 

over the great trochanter continued to increase nntil the end of 
January ; in February it began gradually to diminish, and towards 
the end of the month it had nearly disappeared. Wishing to 
watch the efforts of nature in this case, we prescribed no local ap- 
plication. We ordered mercurial frictions to the nurse every 
second day ; and on the second of March no trace of the tumor 
remained. The periostitis in the fore-arm was more obstinate, and 
led me to apprehend even an alteration in the bone ; the motions of 
the arm were very limited ; the child appeared to suffer ; the in- 
teguments became red ; emollient cataplasms were applied, which 
subdued the inflammatory symptoms, but the tumor remained 
stationary, and the pustules disappearing but slowly, we adminis- 
tered during the month of March corrosive sublimate in doses of 
one-twelfth of a grain, which remedy was continued for three months. 
At the end of this time, the symptoms were all removed."* 

M. Laborie has related another case of osseous disease, with 
caries. M. Bouchut remarks that he has seen many instances of 
lesion of bone belonging neither to caries nor to degeneration of 
the periosteum ; it was characterized by a premature hardening of 
the long bones. In infants born before full term, or born dead, 
says M. Bouchut, instead of finding the bones soft, spongy, vascu- 
lar, imperfectly developed and easily cut with the scalpel, I have 
seen the middle of the tibia and the femur solid, compact, ebur- 
nated, so as completely to resist the action of a cutting instrument. 
He states, that he attaches no importance to this modification in 
structure, which still possesses sufficient interest to be noted here ; 
it seems to indicate in the osseous evolution a degree of abnormal 
and premature activity, on the part of the plastic secretions ob- 
served in several other organs. (Bouchut, loo. cit.) Yery possibly 
these osseous lesions have no connection with syphilis. 

Chancre is still more rare if indeed it has been at all observed 
in the child. Infantile syphilis, therefore, is limited to the second- 
ary accidents, and to the ophthalmia that I shall presently describe. 
Some have established a connection between the form of the acci- 
dent manifested in infantile syphilis and the stage of the disease 
present in the parents at the period of conception. Thus, accord- 
ing to this idea, parents affected with a precocious syphilitic erup- 
tion, will beget children with an erythematous eruption ; at a more 
advanced period, as about the termination of the second stage of 
syphilis, the children begotten will suffer from the deeper seated 
syphilitic eruptions, such as the tuberculata ; at a still later stage, 
they will produce only scrofulous children. Observation has not 
yet sanctioned this triple hypothesis. 

I cannot conclude my remarks on the symptoms without notic- 
ing purulent ophthalmia in the new-born child. Certain it is that 
this serious affection of the eye may be independent of all venereal 
disease, that it may proceed from atmospheric influences, and un- 
fortunate hygienic conditions. But there are cases in which this 

* Bertin, Traite de la maladie venerienne chez les en/ants nouveau-nes, les femmes 
enceintes, les nourrices. 



INFANTILE SYPHILIS. 403 

ophthalmia bears too strong a resemblance to that described as one 
of the accidents of blennorrhagia in the adult, to be here passed 
over in silence. Further, during my connection with the Lourcine 
(nurse department), I constantly observed this severe form of 
ophthalmia among them. Now it is well known that the majority 
of nurses at the Lourcine are subjects of the venereal disease. 

The symptoms of this ophthalmia resemble those of the blennor- 
rhagic ophthalmia already described; tumefaction, redness, dis- 
charge, pain, photophobia, all symptoms common to both. There 
are, however, some slight differences worthy of note. Thus, War- 
drop has observed that the cornea itself is swollen, this membrane 
in children being of a very spongy nature, the palpebral conjunc- 
tiva is most tumefied and frequently forms a hernial tumor ; the 
tarsal circle, therefore, strangulates this membrane, and we observe 
in the eye a phenomenon analogous to that seen on the penis in 
cases of paraphimosis. On separating the lids in the morning we 
sometimes witness an escape of fluid ; so abundant is it, and so 
speedy its reproduction, that it forms a kind of jet whenever the 
child cries ; this fluid never escapes entirely ; a portion always re- 
mains on the globe which can be detached only by injections with 
an ear-syringe. 

This ophthalmia generally appears about the third day after 
birth. At the commencement of the attack the child shuns the 
light ; on separating the lids, the palpebral lining is observed to 
be preternaturally red ; it has a villous appearance ; and on it 
there is formed a thin layer of whitish matter. As the progress of 
this disease is sometimes insidious and very rapid, the closest at- 
tention should be given to the symptoms announcing the onset of 
so serious an affection, in order that it may be at once arrested. The 
terminations of this malady resemble those of the purulent ophthal- 
mia in the adult; with the exception that death, which is very 
rare at the latter period, is in the child not an unusual result. The 
cornea is liable to be perforated by mortification and by ulceration ; 
but staphyloma is the lesion most frequently observed. 

Pathological Anatomy. — Under this head I include the lesions 
which have been observed only on the cadaver. As yet there are 
no particular symptoms by which, during life, they may be de- 
tected. M. P. Dubois has seen lesions of the thymus gland in 
several children born of parents who themselves presented evi- 
dences of constitutional syphilis. Scattered through the thymus 
he detected small foci of inflammation and suppuration. Exam- 
ined under the microscope, as yet these have presented nothing 
unusual. 

In the lungs have been found lobular nodosities, with a grayish 
plastic congestion and suppuration. These nodosities resemble 
those of lobular pneumonia previous to birth, in the fact that they 
often coincide with the existence of syphilitic pustules. Ollivier, 
Billard, MM. Cruveilhier and Husson have advanced nothing fur- 
ther in reference to the connection of these viseeral lesions with 
syphilis. But M. Depaul has gone so for as to assert that these 
plastic nuclei were not the result of lobular pneumonia, but that it 



464 VIDAL ON VENEREAL DISEASES. 

is a particular lesion observed only in connection with other 
syphilitic phenomena in the child or parents ; in that case, being 
a specific alteration produced by constitutional syphilis. The 
coincidence of these visceral with external syphilitic lesions in the 
child, or infection on the part of the parents, with M. Depaul is a 
sure criterion of their nature. He has defended this doctrine in an 
essay read before the Academy of Medicine. M. Caseaux, his re- 
porter, objects to the conclusions of his colleague, believing that 
these alterations may result from inflammation not specific in its 
character, and may therefore be independent of the influence of 
syphilis. M. Caseaux here shows himself a decided anatomist. 
He requires a lesion to prove the nature of its first cause. M. De- 
paul would establish the fact by the preceding and concomitant 
circumstances of the case, &c. 

M. P. Dubois comes with facts and the weight of his authority 
in support of the doctrine of M. Dupaul, who, however, has not 
far outstripped the actual state of the science. But, in the mean- 
time, a practical question constantly arises, which cannot be eluded 
or postponed in the same manner as an academic question. I have 
stated that in such cases we must appeal to common sense, and 
treat the parents as syphilitic, the treatment being attended with 
no danger. In this manner we shall most generally prevent the 
birth of syphilitic children. (Vid. p. 347.) 

We are indebted to M. Gubler for the knowledge we possess on 
the subject of hepatic affections in the new-born child. I insert in 
this place the substance of what he has published on these affec- 
tions. 

M. Gubler distinguishes a general and a partial affection of the 
liver. In the first case, and when the alteration is carried to its 
highest degree, the gland presents a yellow color, quite different 
from that of the liver in its normal state, and resembling that of 
certain flint-stones. The natural appearance of the. substance of 
both lobes is completely lost, with the exception that on the uni- 
form yellow base, by close attention, we may discover a patch 
more or less distinct of opaque white grains, having the aspect of 
hard grains of wheaten flour, together with delicate arborizations 
produced by the empty blood-vessels. 

" The liver is sensibly hypertrophied, globular, turgid, hard, and 
with difficulty divided with the fingers, which tear it without leav- 
ing any impression on its surface. Such is its elasticity, that, if it 
be pressed strongly between the fingers, as if to crush it, a cunei- 
form portion from its margin escapes, like a cherry-stone, and re- 
bounds on the floor ; when cut, it grates beneath the knife like an 
encephaloid mass. The incisions made into this altered liver are 
very clean, homogenous, and, owing to its great consistence, very 
thin slices may be removed, possessed of a demi-transparence, which 
is found to a certain extent in the portions of the organ naturally 
thin, as at its margin, and especially the prolongation which ter- 
minates the left lobe. 

" On pressing an incised portion of the liver, no blood escapes ; 
but from the cut surfaces there oozes very abundantly a limpid, 



INFANTILE SYPHILIS. 465 

slightly yellow-tinged serum, which escapes equally in the end 
thougn no pressure be made. In both cases, this tends to render 
the organ less turgid and more flaccid, by which we might be de- 
ceived if called upon to pronounce on the existence of the lesion. 
This serous fluid coagulates under the same circumstances as 
albuminous solutions, of which I satisfied myself in the following 
manner : having cut a portion of the liver into small pieces, I mac- 
erated the latter for some minutes in water, being careful to stir 
it ; the clear liquid thus obtained, being afterwards exposed in a 
tube to the heat of an alcoholic lamp, became turgid at the moment 
of boiling, with flocculent layers having completely the aspect of 
xoagulated albumen. The fragments, when in turn boiled, became 
hard, white, and opaque. 

" In one case where, three days after death, I endeavored to 
detect the presence of the sugar of diabetes, as demonstrated in 
the healthy liver by M. C. Bernard, I did not succeed with the 
double tartrate of copper and potash. The absence of a normal 
product of secretion in an organ so profoundly altered, is not sur- 
prising. It may be objected to the experiment, that its negative 
results was owing to the length of time which had passed after 
death, and that the saccharine matter that had previously existed 
had consequently disappeared. 

" Such are the principal characters of the syphilitic alteration 
of the liver when carried to an extreme, such as were observed in 
three of our cases. But this alteration may not always be so evi- 
dent and so general; perhaps it most generally assumes other 
forms, which we will here consider. Among these, the most com- 
mon is distinguished from the preceding by the degree of the 
lesion, which besides remains undetermined. Its characters, al- 
ways much less decided, are sometimes so little developed, that 
until the present time, it has escaped the attention of those not 
prepared to meet with it, and in the future, it will doubtless often 
pass unnoticed, on which account it is the more necessary that we 
describe the means of detecting it. The liver, of smaller size than 
in the first variety, may not vary much from that which is natu- 
ral ; it is firm, without presenting the excessive hardness noticed 
in the other cases, and it retains in part the color which we have 
compared to that of silex. This yellow color is observed more 
particularly at its circumference, that is, in the superficial layer of 
the hepatic tissue, and consequently along its anterior border. 
The interior of the organ presents rather an indefinite color of a 
yellowish or brownish red tinge, more or less delicate. No por- 
tion of the parenchyma appears perfectly sound. 

" At the same time, the liver possesses a certain demi- transpar- 
ence, which permits us to distinguish, at a little depth, the grains 
like those of wheaten flour scattered through its substance. Those 
opaque points are here much more numerous and firm, and this 
granulated appearance discovered on attentively examining the 
parts, seems to me to be one of the best indications of the patho- 
logical alteration, of which the liver is then the seat. Indeed, 
these opaque grains in the midst of the slightly translucid sub- 

30 



±66 VIDAL ON VEXEREAL DISEASES. 

stance, reproduces to a certain extent the aspect of both substances 
which contribute to form the hepatic tissue ; but besides the fact, 
these grains are separated by very wide intervals, the surrounding 
substance does not much resemble the essentially vascular weft of 
the areolar spaces of the sound tissue. Further, it must not be 
forgotten that the liver presents very different appearances in in- 
fancy and in later periods of life. 

" This gland, excessively developed in proportion to the size of 
the child, preserves for some time a considerable relative volume, 
which afterwards gradually diminishes, so that it is actually 
smaller at the end of the first month than at the time of birth. 
Thus, in an infant at full term, which had indeed the liver of ar% 
abnormal volume, the transverse diameter of this organ, measured 
over the convexity of its superior surface, was six inches ; the 
antero-posterior diameter of the right lobe four and one-third 
inches ; that of the left lobe, three and two-third inches ; whilst in 
an infant of one month, which appeared to me large when com- 
pared with the organ in subjects of that age, the transverse diame- 
ter, measured on its plane surface, was only four and two-third 
inches. The antero-posterior diameter of the left lobe scarcely 
equalled three inches, that of the right lobe slightly exceeding this 
number. 

" At birth, the hepatic tissue in color resembles that of the 
spleen, and although its brownish-red color gradually loses its 
intensity, it still remains sufficiently deep during the early months 
of extra-uterine life to distinguish it from the yellowish hue be- 
longing to the altered fiver, which, on the contrary, more nearly 
resembles the natural color in the adult. As to the transparency, 
the reverse is true, for the liver of the adult is opaque, even in 
thin slices, whilst that of the very young child is evidently trans- 
parent under the same circumstances, thus diminishing the value 
of the character of the syphilitic alteration, if the latter be not 
generally accompanied with a transparency much more decided, 
together with a more or less yellowish tinge. This opacity of the 
liver in the adult, compared with that of the child, seems to me to 
depend upon two principal circumstances ; first, on the predomi- 
nance of the fibrous tissue, second, on the large proportion of fatty 
matters accumulated in the proper cells. The difference in the 
latter respect is still more striking. 

" The granular aspect, and the appearance of the two substances 
which result, are wanting in the liver of the new-born child ; but 
they exist in a decided manner at the period of life now under 
consideration, that is, towards the end of the second or third 
month from birth. Further, at this age, the healthy fiver, when 
incised freely, discharges the blood with which it is filled, a cir- 
cumstance which does not happen in the liver that has suffered 
the morbid alteration already described. The anatomical diagnosis 
of this alteration appears to us always possible when the circum- 
stances mentioned are taken into consideration. It is well to be 
acquainted with a last cause of error, which I proceed to notice. 
When we press a portion of healthy liver between the fingers, at 






INFANTILE SYPHILIS. 4^7 

the points where pressure is made, the blood contained in the 
capillary networks is expelled, thus causing the substance of the 
liver to assume its proper color, which, as all are aware, is of a 
more or less yellowish tinge. These yellowish or tawny spots may 
be mistaken for diseased portions in the midst of the normal tissue, 
if unacquainted with its true cause ; but the hollow imprint left 
by the fingers or any other compressing substance, and particu- 
larly the absence of a certain transparency, together with the pos- 
sibility of causing the blood to return again by pressure, are so 
many characters which may lead us to an accurate diagnosis."* 

Causes. — The new-born child may be infected by the mother, 
father, or the nurse. 

1st. Influence of the Mother. — Such are the intimate connections 
existing between the mother and the foetus that the poison affecting 
the one must necessarily affect the other. We have only to con- 
sider the circulation of blood existing between the two, to be satis- 
fied that the infection must be mutual. Therefore we here see the 
possibility of transmitting constitutional syphilis by the blood. 

The mother may become infected before conception, or during 
pregnancy. In the first case the child is almost certain to become 
diseased. If the germ is not altered, the embryo, the foetus becomes 
infected. In the second case, where the infection of the mother 
occurs after conception, it has been asked if that of the foetus may 
take place at any period of pregnancy. To this we may reply, 
that the nearer the infection of the mother is to conception, the 
more reason will there be to apprehend that of the foetus. But at 
what period of pregnancy may these apprehensions cease ? This 
point is not yet determined. The infection of the foetus after con- 
ception may result from the infidelity of the husband or the wife. 
When the husband is guilty there is less difficulty in ascertaining 
the period at which the mother and the child became infected, but 
when the infidelity has been on the part of the mother the diffi- 
culty is greatly increased, and if the woman lack sincerity, may be 
even insurmountable. , 

The question has been asked whether it be possible for the foetus 
to become infected during any of the stages of syphilis with which 
the mother may be affected. It is probable that the infection will 
be more certain, more frequent during the more active stage of the 
disease, as, for example, when eruptions exist together with affec- 
tions of the mucous membranes, and that these will be the lesions 
communicated to the child. However, I believe that we are not 
warranted in asserting that a woman affected with tertiary symp- 
toms will not give birth to a syphilitic, but to a scrofulous child. 
It is certain that parents laboring under tertiary accidents have 
been known to beget perfectly healthy children, as well as those 
which were scrofulous, but it is equally certain that they have 
begotten those which were syphilitic. Parents with secondary 
symptoms have produced similar families of children, and unfortu- 

* Memoire sur une nouvelle affection dufoie {Gazette Medicate du 24 Jlai au 5 Juiu, 
1851. 



408 VIDAL OS" VENEREAL DISEASES. 

nately, those perfectly healthy have been known always to procre- 
ate scrofulous children, or those whose prospects for life were very 
doubtful. 

2d. Influence of the Father. — The question of the transmissibility 
of syphilis by the father is involved in the mysteries of conception. 
This point is still shrouded in obscurity. Analogy, however, and 
even certain facts, give us some encouragement for its solution. 
Thus, it is evident that the father may exert a very decided influ- 
ence on the features, form, and moral disposition of the child ; he 
may also transmit to it his morbid dispositions, the germ of certain 
diseases with which the mother has never been affected. We may 
therefore suppose that syphilis may be transmitted by the father 
to the child, the mother remaining sound, thus implying an altera- 
tion of the sperm which vitiates the ovum. This supposition is 
corrobated by the most authentic facts ; they may be found in the 
practice of all writers on syphilis, of all accoucheurs. M. Eicord 
himself has lately stated to the Academy of Medicine, that he has 
treated a woman, who in succession had two syphilitic children, 
although she and her lawful husband had never been diseased. 
The father alone of these children (the lover) was syphilitic.* 
Thus the sperm was here altered ; it had vitiated the ovum only, 
the mother remaining in perfect health, as before conception. 

The ovum may be vitiated by the father not only whilst certain 
syphilitic accidents are manifest, but even after their disappearance, 
at least while there is no external evidence of the existence of the 
diathesis. This fact is admitted by the most reliable practitioners. 
It is expressed in the following letter in terms which admit of no 
question. Like every intelligent person, M. Lallemand addresses 
himself to common sense. He thus writes to M. Baumes : 

" I find that you have been rather too skeptical in reference to 
the virus, or at least, that you have announced your opinion with 
extreme caution. You have, it is true, very well shown the diffi- 
culties encountered in attempting to establish many facts; but 
there are still some^ of which there can be no doubt ; for example, 
when I see a father and a mother in whom no symptoms of syphi- 
lis can be discovered, (the father alone having previously had con- 
stitutional syphilis,) begetting four children, which die, having 
pustules and other symptoms of the disease ; when I see the fifth 
child covered with similar pustules when three or four months old, 
and see this child infect two nurses ; when I cure this child with 
baths of corrosive sublimate and a mercurial treatment ; in fine, 
when after an anti-syphilitic treatment administered to the parents, 
I see four other children enjoy the most perfect health for more 
than ten years, how is it possible to deny that the virus existed in 
the sperm of the father, and that the poison has passed from the 
child to the nurse?" 

The impression of the sperm upon the ovaries may be Such, 
that not only will the first product be influenced by the sperm, 

* Vid. report of the discussion on pemphigus of the new-born child {Gazette 
medicate, Sept. 20th, 1851.) 



INFANTILE SYPHILIS. 469 

but still other products, and that too after copulation with differ- 
ent men. The following fact, recorded in several works on Syph- 
ilis, and which was observed during my connection with the 
Lourcine, will give my idea on the subject. It is that of a woman, 
whose first husband had an obstinate attack of constitutional 
syphilis ; from this union she had one child, that died with the 
most evident signs of syphilis. This same woman, after the 
death of her husband, was married again to a perfectly sound 
man ; she herself was healthy — that is, there were no external 
signs of disease — yet, four years after her first marriage, and after 
having had connection with her second husband, she was deliv- 
ered of a child equally syphilitic with her first ! 

This case appeared to me inexplicable, unnatural, and I confess 
I should strongly have doubted it, had it not come under my own 
observation, but physiology has since taught me that it was in ac- 
cordance with natural laws. I have learned, indeed, that certain 
females may bring forth children bearing a resemblance to the 
first male with whom they had connection, and this too, when 
they have long been separated from that male, and when they have 
become impregnated by another male. Indeed, in the work of Mr. 
Acton I read that a certain lord, residing in India, was desirous 
of obtaining a race of horses with a cross of the zebra. A mare 
was covered by a zebra. The result was a colt having very char- 
acteristic marks of the zebra, among others, the black circles on 
the legs and shoulders. 

This mare was afterwards separated from the zebra and covered 
by horses ; she was three times with foal, and each time the foal 
bore distinctive marks of the zebra, from which the mare had 
long been separated. Thus, by the act of the first fecundation, 
such had been the impression made on the mare, that not only the 
ovum impregnated by the zebra, but the three others by the horse, 
resulted in the production of zebras. We know, besides, how 
long a bitch of a good breed, impregnated at first by a dog not of 
the same blood, will for two or three successive litters bring forth 
a mongrel breed.* 

The following case shows the prolonged influence of syphilitic 
infection on the part of the mother. It has been published in a 
pamphlet by M. Yassal. The case is that of a widow, C, who 
laboring under symptoms of syphilis, was subjected to a thorough 
treatment, under the influence of which she seemed to have recov- 
ered. Having married again, some time afterwards, she had in 
succession two children, both of which died with evident symptoms 
of syphilis. The second husband died soon afterwards from 
typhoid fever, without having ever suffered from venereal disease. C. 
married for the third time, and from this union she had twins, 
which died with evident marks of syphilis; she was delivered 
again of a fourth child, a male, which soon presented a corona ve- 
neris, but which soon became cured under the influence of a mer- 
curial treatment. And yet, says M. Yassal, since her treatment, 

* Vid. Acton, (op. tit p. 412). 



470 VIDAL ON VENEREAL DISEASES. 

the woman C. has not ceased to enjoy good health ; she has had 
no new symptom of venereal disease ; has communicated nothing 
to the men with whom she has had connection, and yet she has 
infected every child which she has brought forth. 

M. Cazenave, who has also reported this case, notes a circum- 
stance which can leave no doubt as to the nature of the accidents 
under which these children labored, viz., the second child infected 
its nurse. 

The most striking fact in this part of the etiology, is that of the 
transmissibility of syphilis to the germ by the semen, that is, by a 
product of secretion ; a fact admitted by a partisan of the Hun- 
terian school, which denies the syphilitic alteration of the products 
of secretion ! Another important fact is the following, also ad- 
mitted M. Eicord , viz. : the mother who escaped syphilitic infec- 
tion after copulation with an individual laboring under the vene- 
real diathesis, this same mother who remained sound after impreg- 
nation, may become infected from the foetus, the germ of which 
has been contaminated by the semen of the same individual.* 

Thus, by an interchange facilitated by the circulation existing 
between the mother and the foetus, when the latter is syphilitic, it 
may communicate the disease to the mother, as may the mother to 
the foetus, when she herself is infected. I beg the reader to pon- 
der over this fact of the ovum contaminated by the father, the mo- 
ther remaining at first sound, and afterwards to consider the fact 
of this mother who receives the infection from the child she carries 
in utero, which child likewise contaminates its nurse ; I beg the 
reader to follow the virus in its course, and afterwards tell me if it 
is in accordance with these facts and their philosophy to assert 
that the virus, when once the primary accidents have been de- 
stroyed, is impotent when removed from the person infected ; that 
when once admitted to the circulation it is no longer capable of 
being transmitted ! 

There is still another question. Both parents being sound, 
and having never suffered from syphilis before the mother be- 
came impregnated, when pregnancy once exists can the ovum 
become infected through the influence of the father alone, who 
may have contracted the disease during the pregnancy of the 
mother ? This point has not yet been determined. The nega- 
tive may reasonably be inferred, and it is supposed that for 
the contamination of the ovurn, the mother must first become 
infected. 

[Mr. Porter, in the Lecture from which we have already quoted, 
relates a case (Dub. Med. Press, Feb. 17, 1847, p. 100) which would 
seem to settle this question in the affirmative. The child was be- 
gotten three months before the father contracted the disease, the 
mother was sound, with the exception of some spots of button 
scurvy, yet the child, when born, was syphilitic. — Gr. C. B.] 

3. Influence of the nurse upon the child, and vice versa, and upon 
those who have their earliest care. — The new-born child may receive 

* Yid. Acton, op. cit. 



INFANTILE SYPHILIS. 4.IJI 

from the milk of its nurse poison instead of nourishment, and it is 
true it may infect the nurse. Indeed, nurses under the influence 
of the syphilitic diathesis, and yet having no external evidence of 
this diathesis, have communicated syphilis to sound children, born 
of sound parents. In these cases the milk has been the vehicle of 
the poison. 

[Mr. Travers argues that as the natural secretions, "by a most 
happy economy," however they may deviate from a healthy stand- 
ard, cannot be the vehicle of the syphilitic poison, so the milk of a 
syphilitic nurse cannot affect the child, (Pathology of Yen. Affec- 
tions, Lond. 1830.) But it is clearly proved, as we have already 
shown, by abundant testimony, that contrary to the opinion of 
Mr. Travers, and the disciples of Hunter, the semen of the syphil- 
itic male may infect his paramour ; this law of Hunter as regards 
the natural secretions, can therefore no longer be maintained. Mr. 
Colles, (op. tit. p. 385,) observes, " I have never seen or heard of a 
single instance in which a syphilitic infant (although its mouth be 
ulcerated) suckled by its own mother, had produced ulceration of 
her breasts." Mr. Egan (op. cit. p. 317) remarks, that he can safely 
vouch for the accuracy of the above statement, and similar testi- 
mony is furnished by Mr. Acton, (op. cit. p. 419,) and Mr. Hennen, 
(Military Surgery, p. 558.)— Gk C. B.] 

It has been supposed, also, that children have infected their 
nurse by the saliva which they have deposited on the nipple dur- 
ing the act of suckling. Cases, however, tending to show this 
effect, it is well to add, are wanting in those details required to 
carry conviction to the mind. Yet they have analogy in their 
support ; indeed, it is generally admitted, even by the most de- 
cided partisans of the Hunterian school, that syphilis may be com- 
municated by the semen ; now saliva and milk are products of 
secretion, and like the semen may therefore become the vehicle of 
the syphilitic poison. I repeat that it is very difficult to establish 
cases of infection by the milk and saliva, independently of all ex- 
ternal evidences of the disease. It is still more difficult to decide 
in certain cases, when syphilitic symptoms appear, whether the 
nurse or nursling has communicated the poison. 

As to the infection of the nurse by the child, presenting exter- 
nal evidences of the disease, nothing is better proved, and cases 
of the kind abound. Every physician of much practice, and every 
accoucher, especially those who devote especial attention to the 
diseases of children, are in the possession of facts proving this 
contagion. They may be found in the works of writers on syph- 
ilis who admit the transmissibility of the secondary accidents, and 
even of those who reject this doctrine. Thus Hunter has recorded 
several cases of the kind. The following is an analysis of the 
first. It is copied from the work of M. Bouchut, who declares 
himself a believer in contagion : 

" A child was accused of having infected its nurse. The father 
had had gonorrhoea two years before his marriage, and fourteen 
years before the birth of the child. Both the first and second 
child were born healthy. The third died at the end of the fifth 



472 VIDAL Otf VENEREAL DISEASES. 

month. The fourth was born at the seventh month, scarcely cov- 
ered with epidermis, affected with dysentery, and died almost im- 
mediately. The fifth was born at the eighth month, of wretched 
appearance, and in the course of a few days, the surface of its 
body, and the interior of its month, were covered with vesicles 
filled with a clear pus ; it died at the end of the third week ; it 
had been confided to the care of a nnrse. The latter, shortly after 
the death of the child, was affected with ulcers on the nipple, swell- 
ings in the axillce, very sore throat, without ulceration, followed by a 
cutaneous eruption, with loss of the epidermis of the hands and 
fingers, and onyxis, with loss of the finger and toe-nails." 

Hunter, says M. Bouchut. denies the existence of syphilis, both 
in the child and nurse. He attributes the ulceration of the fingers 
and the loss of the nails in the nurse, to the influence of mercury. 
But it is worthy of note, that Hunter, in denying the existence of 
syphilis, is not able to pronounce upon the nature of the disease. 
But whatever else it may be, in his estimation, it was not syphilis. 

Here is another case from Hunter. It is taken from a corner 
where, says M. Bouchut, it is very difficult to find it ; it is dis- 
guised under the title of diseases resembling syphilis. Hunter had 
all the failings of men bound down to systems, and who discard 
whatever perplexes them. A case is encountered which clashes 
with his theory, it is the case which is wrong, it is an aberration 
of nature, according to these masters of nosology.* 

" A woman nursed two children, giving to her own the right, 
and the other the left breast ; at the end of six weeks the left nipple 
ulcerated and was finally destroyed ; the ulcer healed three months 
from the commencement of the accident. Then, the strange child 
became affected with shortness of breathing, aphthae in the mouth, 
and died from consumption, its body being covered with ulcers. 
Soon afterwards the nurse was seized with lancinating pains in 
different parts of the body, and patches of eruption appeared on 
her arms and thighs, several of which became ulcers ; she was sub- 
jected to a mercurial treatment. 

" Three years afterwards she had a child, the epidermis of which 
was detached at several points, the body presented a squamous 
eruption, and which died at the end of nine weeks. It had been 
placed under the care of a nurse ; the latter, shortly afterwards, had 
cephalalgia, pain in the throat, and ulcerations on her breasts ; she 
entered a hospital, and although treated with mercury, she left un- 
cured at the end of some months. The nasal and palatine bones 
exfoliated, and some months afterwards she died from consump- 
tion. 

" The mother employed sea-bathing and the Lisbon tisane. The 
ulcers on her arms and thighs were cured in the course of a month. 
A year afterwards, she had another very feeble child, which died 
at the end of one month. Finally, ten months afterwards the 



* I quote M. Bouchut here literally, to show that young and active members of 
the profession are opposed to the Hunterian doctrines, for it has been charged that 
such opposition is confined to those who are behind the age. 



INFANTILE SYPHILIS. 473 

ulcers reappeared, suppurated for a year, and at length disappeared 
forever. 

" What," says M. Bouchut, " was this dise'ase that passed from the 
child to the breast of a woman, infected her system, produced 
lesions of the skin, and caused her to bring forth a child covered 
with ulcers, which child infected another nurse, whose breasts, 
pharynx, and bones become so deeply affected, that she perished ? 
What was it, if it was not syphilis or a syphaloid disease, a term 
which Hunter has sought without being able to find ; for, in speak- 
ing of this case, he thought that new poisons were daily formed 
strongly resembling the venereal poison ; so that it was not from 
their points of resemblance, but dissemblance, that he formed his 
conclusions."* 

As might be supposed, this case of Hunter's, so opposed to his 
doctrine, has found other commentators. Thus, M. Cazenave re- 
marks in his journals ; " if we examine the ensemble of phenomena 
in this case, we see a woman adopting a strange child to nurse, 
and giving it in particular its left breast. Now, it was the nipple 
of this breast that became the seat of the ulcerations which com- 
pletely destroyed the part affected. These ulcers were accompa- 
nied with glandular enlargements in the axilla ; and to abridge the 
first part of this history, the adopted child died with all the signs 
of advanced cachexia. Subsequently, this same woman brought 
forth a second child, and confided it to another nurse. The child 
died with a squamous eruption, which covered its whole body. 
As to the nurse, her breasts became ulcerated, she had cephalalgia, 
necrosis of the nasal and palatine bones, and died cachectic. Fi- 
nally, to conclude this sad episode, the mother of these two chil- 
dren had a third, which also died at the end of a month, and she 
herself was cured only after many relapses, and a great variety of 
treatment. It is difficult not to recognize in this case a new proof 
of the possibility of the infection of the nurse by the child, and 
the indefinite transmissibility of syphilis in this manner. Like- 
wise, with Babington, we cannot admit the merit of the negative 
argument drawn from the pretended non-contagion of secondary 
accidents. It is upon the latter point, however, that writers of the 
modern school of syphilis found their arguments for denying 
any kind of infection than that by an unequivocal and primary 
chancre.f 

Babington, the judicious annotator of Hunter, admitting the 
communication of syphilis from the mother to the child, and from 
the latter to the nurse, comments, or, more properly speaking, 
combats the views of his countryman, and that, too, with a great 
number of cases proving this contagion. He mentions with much 
care the syphilitic phenomena observed in the new-born child, 
infected by its parents, and does not hesitate to admit that persons 
thrown into very intimate contact with a child affected with this 
disease, may thereby become affected. This contagion, in his 

* Bouchut, loc. cit. 

f Annates de la syphilis et des maladies de la peau, No. for August, 1851. 



474 VIDAL ON VENEREAL DISEASES. 

opinion, may thus take place to an indefinite extent. Babington 
believes (and this should be carefully noted), that it is at least 
very difficult to deny that cases like those cited by Hunter are not 
the effect of venereal poison, even in admitting that, in children, 
the symptoms of syphilis are not precisely the same in their pro- 
gress and aspect as in the adult. He believes, in fine, that it is 
impossible to admit Hunter's argument, that secondary accidents 
are not contagious. 

Finally, M. Eicord adds the following to the note of Babington: 

" I coincide completely with the views expressed by Babington; 
only I believe that, as yet, we know not how to determine the ab- 
solute nature of the accidents which may be transmitted from the 
child to the nurse ; and I believe also that the accidents reputed 
secondary and transmissible, may at first have been primitive ; as 
likewise, in certain cases, the nurse who pretends to have been 
infected by the child, may have otherwise contracted the disease. 
However it may be, in the actual state of the science, if this ex- 
planation still leaves much to be desired to completely satisfy the 
mind, there exists a great number of incontestible cases of syphilis 
transmitted from the child to the nurse, and vice versa."* 

Of what consequence is it that the secondary accident of the 
child was at first primitive ? So long as it is actually a secondary 
accident that is transmitted, the question is decided in favor of the 
contagionists. What if the nurse does sometimes unjustly accuse 
the child, when it is known that she actually does occasionally 
become infected from this source ? Let us admit that these unfor- 
tunate nurses have occasionally suffered much both in reputation 
and interest from the doctrine laid down by Hunter. When they 
have presented only secondary accidents, they have been told that 
the primary had passed ; when, from the previous history of the 
case, and a careful examination of the husband, it has been found 
that the latter was never affected with syphilis, then a lover has 
been imagined. All this certainly may be true, and I would not 
guarantee either the veracity or the morality of every nurse. 
But it is none the less true, that some of them have been carefully 
inspected before they took the child, and have been pronounced 
in perfect health, before it would be confided to them. Yet I 
have seen nurses which had been thus examined and declared 
sound, become covered with syphilitic pustules, which they justly 
attributed to the child, which had not been examined before quit- 
ting its parents. The following is an instance of this kind that 
cannot be questioned : 

" M. P., several days after a suspicious connection, discovered a 
chancre on the prepuce. During the first stages of this chancre, it 
being yet undiscovered, he had intercourse with his wife, then 
seven months advanced in pregnancy, and communicated to her a 
similar chancre. I treated both with Van Swieten's liquor and 
sudorifics. The husband was cured in twenty -five days ; the ulcer 
on his wife was also readily cured, but there followed coppery 

* JSTotes to Hunter, 2d ed., p. 116. 



INFANTILE SYPHILIS. 475 

papules on the forehead, and ulcers on the tonsils. In the mean- 
time, she was delivered of a child, to all appearance very healthy; 
this child was placed under the care of a servant, who had been 
seduced and confined in a maison de sante. This nurse, having 
first been carefully examined in the genital organs as elsewhere, pre- 
sented no evidences of syphilis. She was constantly watched, and 
went out only in company with the mother of the child. Eighteen 
days after the birth of the child, reddish, elevated spots appeared 
on the nates, chest, and cheeks ; in the centre was a pustule ; to 
the pustule succeeded a roundish, characteristic ulcer ; in a word, 
they were true pustules of syphilitic ecthyma. For twelve or fif- 
teen days the nurse presented nothing new ; but then some ulcera- 
tions, with a grayish, irregular, cut out base, appeared around 
both nipples, a similar ulceration invading the commissure of the 
lips ; around the anus were mucous tubercles, and there were 
furfuraceous coppery spots over different portions of the skin. 
Both were cured, in the course of forty-five days, by the syrup of 
Cusinier and Yan Swieten's liquor, given to the nurse, and the 
application of the sublimate baths to both nurse and child. As 
to the mother of the child, she was cured by a continuation of the 
same treatment which was resumed after her confinement."* 

Further, there is a comparison to be made which seems to me 
to settle the question of the transmissibility of secondary accidents 
from the child to the nurse. Even admit the existence of chancre 
in the infant, as is maintained by the disciples of Hunter, yet it 
must be acknowledged that it is very rare ; so rare, indeed, that it 
would be difficult to assign to it its most frequent seat, and no 
separate description of it can be found. For my part, says M. 
Gibert, I have never seen primary symptoms in the new-born 
child.f Now, compare the extreme rarity of these symptoms with 
the frequency of infection of the nurse by the child, a frequency 
admitted even by my opponents, and it must be acknowledged 
that in this contagion, the so-called secondary syphilis plays the 
principal part, it is that which is most frequently communicated 
to the nurse. 

In spite of these facts, and the admissions of the masters of the 
Hunterian school, which compel them to acknowledge, more or 
less completely, the contagion of secondary syphilis in the child, 
there are disciples of this school who even yet defend the system. 
Among these we may mention Mr. Acton, in England, and M. 
Cullerier, the son, in France, both of whom have written against 
this double contagion of secondary syphilis from the child to the 
nurse, and vice versa. The latter has fully expressed his opinions 
in a memoir read before the Academy of Medicine, based on facts 
which have satisfied him that an infected child communicates 
nothing to its nurse, and that the latter, though fully saturated, 
transmits nothing to the child. But these facts of M. Cullerier, 
like those of Mr. Acton, have only a negative value ; they avail 

* Baumes, t. i., p. 169, et suiv. 

f Manuel des maladies veneriennes, p. 317. 



476 VIDAL ON YENEREAL DISEASES. 

nothing against the affirmative facts, which are very numerous. 
They both pretend that, under certain circumstances, certain syph- 
ilitic accidents are not transmitted. Now, I doubt whether they 
find a single person to dispute this opinion. In like manner, 
should one assert that, under certain circumstances, certain chan- 
cres cannot be inoculated, surely no one would now contradict 
him. But this does not prove that the same accidents, under 
other circumstances, are not transmissible. 

M. Cazenave, who is opposed to Hunter and his followers, men- 
tions in his journal a very remarkable case, in which a sound 
nurse suckled for three months an infant likewise sound, after- 
wards she received another diseased child to nurse, and, from this 
date, 1st, the infection of the first child removed to its mother ; 
2d, the infection of this mother ; 3d, that of a little sister ; 4th, 
finally, the pregnant nurse becomes also diseased, and gives birth 
to a child equally infected. 

"Now," observes M. Cazenave, "to this curious connection of 
facts, to this succession of the phenomena of infection, so rapidly 
following the one upon the other, can there be two explanations ? 
If we adopt the doctrine of the absolute non-contagion of secondary 
accidents, we must accumulate hypothesis upon hypothesis, com- 
mencing with the supposition that the nurse might have been in- 
fected by a primary ulcer existing in the second child, of the ex- 
istence of which ulcer we have no knowledge. If we take into 
consideration the great care with which the details of this curious 
history were collected, the repeated and persevering investigations 
to which the infected individuals were subjected, there remains 
but one reasonable explanation. The second child was the start- 
ing point, the first chain only remaining unknown, in the series of 
phenomena which commenced in the infection of the nurse and the 
daughter, 0. The latter communicated the disease to her mother, 
who in turn gave it to an elder daughter ; finally, the nurse gave 
birth to a child likewise diseased, even after she had submitted 
to treatment, which, it is true, was incomplete. One of the most 
important features in this curious case should especially be re- 
marked, viz., the identity in the impression of the phenomena in 
the different individuals affected ; thus, in none was there any 
trace of chancre, but always, and at all points, it was the mucous 
tubercle. Before dwelling upon this circumstance in detail, I can- 
not refrain from remarking that it is, in this respect, that the case 
differs from that of Hunter, both of which, it is true, lead to the 
possibility of the same fact, viz., contagion, but under very differ- 
ent circumstances, in virtue of which contagion is necessarily more 
constant in one than in the other, and we shall hereafter see that 
the explanation of the phenomena detailed in our case does not 
conflict so much with the opinion of our opponents, if the latter 
were not so fatally bound by their primitive syphilis. 

" Finally, we have also been struck with the kind of regularity 
in the period of incubation. Thus, in the nurse, the syphilitic 
symptoms became developed nearly in the same time as in the first 



INFANTILE SYPHILIS. 477 

child, 0. ; and in the latter, the period of incubation was much 
about the same as that of the elder child."* 

M. Cullerier, the nephew, the worthy practitioner whom I suc- 
ceeded at the Hdjpital du Midi, was a contagionist. He has pub- 
lished as follows : 

" But if we mark the feeble power of contagion, possessed by 
the consecutive accidents of syphilis, we do not pretend that they 
are never communicated by contact. Well-authenticated facts 
show, on the contrary, that certain of them may be thus trans- 
mitted, and it cannot be absolutely affirmed that this observation 
does not apply to others. 

" A genteel married woman presented herself at the venereal hos- 
pital, having a child ten months old, and gave the following state- 
ment : I have never had the venereal disease, and my husband is per- 
fectly healthy ; ten months since I gave birth to this child, which 
was strong and healthy. I took a strange child to nurse ; it was ex- 
tremely emaciated, and its body was covered with an eruption 
such as you now see. Having no suspicion of the nature of the 
disease, I nursed that child together with my own ; they fre- 
quently slept together, and wore each other's garments. I soon 
discovered that my child was affected with a similar eruption to 
that on the foster child ; and, although the mouth of the latter was 
free from sores, yet large scabs appeared upon my breast, back, 
and chest, some of which are still to be seen. The foster child 
soon afterwards died, and it was not until my child had become 
greatly emaciated, that a physician who was consulted, declared 
that both of us had venereal disease. 

" The child was indeed in a deplorable condition, its whole body 
being covered with a pustular eruption ; the mother was similarly 
affected, leaving therefore no doubt as to the nature of the disease : 
the nipple had never been ulcerated." 

Here, then, we have the case of a child communicating syphi- 
lis to its nurse and to another child. In the following instance 
we see the disease still more widely disseminated. 

" Here is another case," says the same writer, " equally in favor 
of the contagion of consecutive accidents. A woman was admitted 
to the hospital, with two children, one aged seven, the other eleven 
years. The following was her story : I reside in the country, ten 
leagues from Paris. I have four children, all of which together 
with their father and myself, have always enjoyed excellent health, 
Eight months since, I took a foundling child to nurse, two years of 
age; it was a wretched-looking child, and had pimples on its 
body and sore throat. We permitted it to take soup with the 
same spoon as ourselves, and to drink from the same glass. Soon 
one of my girls complained of a severe sore throat ; this increased, 
and she died in about six weeks ; the foundling also died ; soon 
after this I began to suffer from an affection of the throat, as did 
these two children; their father suffered nothing, and to this day 
is perfectly well. A physician was called, and suspecting the ox- 

* Annates des maladies de lajpeau et de la syphilis, loc. oit 



478 VTDAL ON VENEREAL DISEASES. 

istence of venereal disease, ordered frictions of mercurial ointment; 
but the affection of the throat did not diminish, and I determined 
to enter a hospital. 

" These three patients all had an ulceration of the posterior wall 
of the pharynx, supposed to be of syphilitic origin. After a mer- 
curial treatment of some months, they left cured ; but the eldest 
child soon returned ; having a pustular eruption over the whole 
body, and was at last cured by fumigations with cinnabar." 

These cases and opinions on the transmissibility of secondary 
accidents may be found in the work of M. Lucas Championniere, 
a work written, so to speak, under the supervision of Cullerier, the 
nephew.* 

Analogous cases, I repeat, have likewise been observed by al- 
most every practitioner of much experience. I possess several 
which are most curious. The most remarkable, in my opinion, is 
that of a little girl in whom mucous tubercles existed in the 
mouth ; she contracted them from a nursling which her mother 
had taken. This little girl was placed in one of the weaning houses 
in the environs of Paris, where it was almost entirely neglected, 
more attention being bestowed on others in consideration of the 
remuneration given. In this weaning establishment there was but 
one tin cup for six little girls. I know not whether she was the 
intermediate one, but four of these children who were previously 
sound, became affected with mucous tubercles in the mouth, and 
on the genital organs, one month after the arrival of the new 
boarder, of the syphilitic nature of whose affection I had satisfied 
myself previous to her departure for the country. 

Diagnosis. — The diagnosis of infantile diseases is attended with 
great difficulties. The elements required, indeed, exist not only 
in the child, but in the mother, father and nurse. Syphilitic erup- 
tions in the child strongly resemble those in the adult. But there 
are some which are analogous to other eruptions not syphilitic. 
Thus, M. Trousseau is of opinion that the yellow tint is more 
common to the eruptions in the child than the coj3pery hue. 
Those who have followed the discussions on pemphigus in the 
new-born child can appreciate the difficulties in deciding upon the 
nature of that which is syphilitic. Some writers believe, that in 
the present state of science, this diagnosis is impossible. This, 
however, I have attempted to establish in describing this form of 
eruption in the child. According to M. Trousseau, there is one 
symptom or accident of great value in forming the diagnosis of a 
syphilitic disease in the child ; that is, the chaps or fissures on the 
hands and feet. This symptom is seldom wanting, but unfortu- 
nately it does not always exist. 

Certain affections of the mouth, as aphthae, or thrush, may im- 
pose upon us for a syphilitic affection, especially if accompanied 
with a cutaneous eruption. This mistake is the more liable to be 

* This -work, indeed, is prefaced with a letter from Cullerier, -which thus com- 
mences: "The work which you are about to issue is the faithful expression of my 
opinions on the nature and treatment of syphilis." 



INFANTILE SYPHILIS. 479 

committed, as certain cases of aphtha?, not syphilitic, are conta- 
gious. The eruption must, therefore, be examined with the great- 
est care, the parents should also be questioned and examined, so 
that erroneous conclusions may be avoided, which might lead to 
the adoption of a mercurial treatment, a practice in some cases not 
unattended with danger. When the symptoms presented by the 
child are doubtful, we should then look to the suspicious source 
of the malady in the parents ; both father and mother should be 
questioned and examined. But the symptoms in the mother may 
not always be evidently syphilitic, but obscure ; still further, she 
may be free from all symptoms, and in fact may never have been 
infected. If the accidents on the father have long been healed, 
and have disappeared, the practitioner may be left in the same 
perplexity. He may have an interest in concealing the truth, and 
may deny ever having had the disease. Finally, a third person 
may be the guilty party, the legal father and mother being both 
perfectly sound, and the infection of the child may be due to this 
third person, whom it is difficult to discover. 

It is evident, therefore, in what obscurity the questions con- 
nected with infantile syphilis are involved. And yet the physician 
may be daily called upon to answer them, in behalf of the parents, 
or of justice! 

I certainly do not condemn the conduct of those who require 
the elements necessary to conviction, and I myself strongly suspect 
the veracity and morality of persons, when it is for their interest 
to deceive. Yet, it must be acknowledged, that in certain cases, 
inquiries instituted by men placed in favorable situations for the 
purpose, may furnish results far more important for producing 
conviction, than qualified scientific data afforded by a single symp- 
tom only. Thus, there are reputable country practitioners so well 
acquainted with all that passes in their district, and who know so 
well the standing of their families, that their testimony should have 
the greatest weight in an affair of damages in which a nurse may 
be concerned, especially if their only opponents are writers on 
syphilis, who have been long wedded to a system now known to 
be false. Judicial tribunals begin to understand the too great 
facility with which nurses may be accused. Thus, the tribunal of 
Meaux recently gave two hundred francs damages to a nurse 
infected by her nursling, because two trusty practitioners of the 
county testified to the fact that the family of the nurse had received 
the poison from the foster child, and this judgment was rendered 
in spite of a certificate from M. Eicord denying the possibility of 
such infection.* 

Prognosis. — The prognosis in infantile syphilis is generally 
grave, for a being tainted with this poison at birth, is one whose 
existence is seriously compromised. But if, aside from the syphi- 
lis, the child at birth is strong, and as the saying is, lively, if it is 
treated early, the prognosis is more favorable, for a euro is then 
not unfrequently obtained; I repeat, if the child be treated early; 

* Vid. Gazette des Hbpitaux, 1851, and the work of M. Bouclmt^ p. 894 



480 VIDAL ON VENEREAL DISEASES. 

and I will add, well treated. I should here observe, that the vis medi- 
catrix naturce in these cases is less powerful than in the adult. In 
the latter, it is not unusual to witness instances of cure which are 
entirely due to this power. Such, however, is not the case with 
the child; a cure in the case of the latter without treatment is 
exceedingly rare. When the child at birth presents a miserable 
appearance, and the mother is diseased and feeble, and when both 
hygiene and treatment have been neglected from the first, the 
prognosis should be very guarded. These are the causes of the 
frightful mortality among children born with syphilis. 

M. Acton has remarked, in a mortality of three hundred and 
three children from this source, that the most fatal period was 
during the first ten months of life. Frequently, if this period be 
passed, they gradually waste away and perish before the end of the 
year. If, by the efforts of nature, by well-directed treatment, good 
hygiene, the infant fortunately reaches the first aniversary of its 
birth, it will have many chances of being raised. 

Treatment. — In speaking of the treatment of the new-born child, 
I cannot refrain from premising a few observations in reference to 
that of the parents, for the latter is sometimes the prophylaxis of 
the child. During my connection with the Lourcine, and my 
charge of the nurse department in that hospital, many of them 
were pregnant, and these I treated precisely in the same manner 
as those who were not. In cases of primitive accidents, I adminis- 
tered the bi-chloride of mercury, according to the formula of Du- 
puytren ; in the consecutive accidents, I gave the iodide of mercury, 
and this too in the same doses as to all my patients. I never 
observed that abortions were more common in women thus treated 
than in those who refused to take it from fear of producing such a 
result. On the contrary, I am convinced, that when properly 
treated with mercury in the early period of their pregnancy, they 
miscarry less frequently, that their offspring will be less deeply 
infected, and that, in some cases, they will be free from syphilis. 
Thus, I believe that pregnant women should be treated with mer- 
cury as early as possible ; it is even a means of preventing abor- 
tion, an accident especially provoked by the diseased state or death 
of the foetus. Now, the sooner the mother is rid of her syphilitic 
infection the greater are the chances that the infant will escape, 
and consequently that pregnancy will continue until full term. 

[Mr. Langston Parker (op. cit. pp. 192, 193) has some very 
judicious remarks on the treatment of syphilitic pregnant women : 
" The result of modern experience shows that a pregnant female 
constitutionally diseased may be treated with safety, and with a 
strong probability of cure both to herself and the eradication and 
prevention of disease in the foetus in utero. It is not prudent to 
commence the full treatment of a pregnant female during the ninth 
month of her pregnancy. At this period a palliative treatment 
only should be adopted ; if a mercurial one, it should consist in 
alterative doses of this drug merely, and frictions with small quan- 
tities of mercurial ointment every two or three days, leaving the 
full treatment to be commenced a month after delivery." Mr. 



INFANTILE SYPHILIS. 481 

Acton advises (op. czt. p. 429) that the female, under these circum- 
stances, should be treated exactly as if she were in an unimpreg- 
nated state. "Observations on a large scale," he observes, "have 
taught me that the fears of the surgeon who dreads to give the 
pregnant woman mercury, are chimerical." Drs. Beatty, Evory, 
Kennedy, and Egan, maintain that " abortion may be prevented, 
and a healthy child insured, by a judicious mercurial treatment 
during pregnancy." (Egan, op. cit. p. 291.) — Gr. C. B.] 

The father should be treated precisely in the same manner, that 
is, in accordance with the principles of therapeutics which I have 
laid down. The question on which writers on syphilis are divided, 
is, whether in the absence of all evidences of the disease, the father 
should be subjected to treatment simply because the mother may 
have miscarried. It is necessary to distinguish here, if the father 
has really had syphilis, if the foetus bears marks of this diathesis, 
there should be no hesitation in submitting the father to treatment ; 
for we know that the disease may remain for a long time latent, as 
is proved by the relapses after long intervals. Indeed, between 
the two manifestations of the disease, we see persons enjoying the 
best of health, and bearing on their body no traces of the diathesis ; 
bnt the latter does not the less exist ; it will probably reappear at 
a later period on the same individual, his child or his wife. "We 
should be guarded when the father assures us that he has never 
been syphilitic, except when we know that he has some particular 
object in deceiving us. In such a case, the shrewdness of the 
physician, and the confidence which he knows how to inspire in 
the mind of the father, may be of great service to the family. 

When a child is born of syphilitic parents, should the father be 
treated ? No, if there are no marks upon him of the disease ; for 
it has been proved that venereal parents have begotten healthy 
children, which have been raised, without even showing the least 
symptom of syphilis. But children of such an origin should be 
carefully watched, in order that they may be properly treated upon 
the very first manifestations of the disease. They should not 
suckle their mother, for, whatever may be the opinions entertained 
as to the alteration of the milk, it is acknowledged that it is better 
that they should be nourished by a woman free from the disease. 
Indeed, if the mother's milk is not syphilitic, if it is impossible for 
it to infect the child (which is not established), it may suffer some 
other change, from the contamination of the system, so as to afford 
imperfect nourishment to the child, or favor the development of a 
diathesis, the germ of which might have been destroyed by a more 
healthy aliment. There are mothers, who, from economy or un- 
easiness of their child, use the sucking bottle instead of committing 
it to the care of a nurse. This, especially in cities, is bad practice. 
Children, I repeat, of such an origin, should be carefully watched, 
and placed in the best possible hygienic conditions. Now, as ali- 
mentation is here the basis of hygiene, a good nurse should be 
selected for the child. Should the child be boru^ with symptoms 
of syphilis, or if these symptoms appear shortly after birth, it must 
be subjected to treatment, for, as I have already stated, if we do 

31 



482 VIDAL 0A T VENEREAL DISEASES. 

see adults become rid of unquestionable symptoms of constitutional 
syphilis, without any specific treatment, it is not the case with 
children of a tender age. Under the influence of hygienic care, 
the symptoms may completely disappear ; but they are certain re- 
peatedly to return, after longer or shorter intervals, and with more 
or less intensity until a fatal termination, which is then "sure to be 
the result. In my opinion, mercury is our proper remedy, and it 
should be administered directly. I find that in this view of the 
subject, M. Cullerier, the son, coincides. This practitioner has 
published an article in the Bulletin Therapeutique, from which I 
have profited. But as this mode of administration is not adopted 
by all practitioners, let us discuss the advantages of the direct and 
the indirect employment of the remedy. 

The indirect treatment, or that through the medium of the nurse, 
has been recommended by many writers on syphilis, or accouch- 
eurs, who, fearing the effects of mercury on constitutions so feeble 
and delicate as those of infants at the breast, and exaggerating the 
gravity of the possible accidents, believe that they can avoid these 
effects by medicating the milk of the nurse, which is thus made to 
serve, at the same time, for nourishment and medicine ; those who 
are afraid of the action of mercury on the mother or the nurse who 
present no symptoms requiring its use, cause it to be given to 
goats and asses, on the milk of which the child is fed, Astruc, 
Fabre, Burton, Eosen, Faguier, Doublet, and Levret, declare them- 
selves the advocates of this method of treatment. 

" Seeing," says M. Cullerier, " such great confidence in the in- 
direct treatment, it is very natural to conclude that it is not the 
result of reasoning alone, but that it is based on researches show- 
ing the presence of mercury in the milk of the females or animals 
to which it has been given. This, however, is not true, and the 
theory of the passage of the mercury into the milk has long been 
regarded as merely an hypothesis, for a truly serious chemical 
analysis has never been made. Many absurd notions have indeed 
been admitted in reference to the action of mercury on the system, 
and if it were possible to believe in its presence in different parts 
of the system, or in the secretions, we might, without proof, admit 
of it in the milk. But let us glance at the authors who have re- 
ported cases of the kind, and see with what confidence they inspire 
us. Thus, Petronius speaks of a syphilitic patient treated by mer- 
curial frictions, in whose urine numberless globules of mercury 
were seen to float; Mussa-Brassavole having seen a patient on 
whose arms and thighs mercurial frictions had been made, attacked 
with vomiting, was astonished at the weight of the matter rejected, 
and, looking in the vessel with the expectation of finding a collec- 
tion of thick phlegm, saw nothing but a large quantity of mercury 
which had been vomited ; Gabriel Fallope, who asserted that mer- 
cury is found in quantities in the saliva of patients affected with 
mercurial ptyalism, and declares that the way to ' arrest salivation 
is to hold a gold ring in the mouth, to draw off the mercury. 
Assertions still more serious have been made, and authors of some 
renown, as, for example, Teller and Buchener, declare that they 



INFANTILE SYPHILIS. 485 

have detected the metal in the bile, blood, saliva, and urine of 
venereal patients who had been treated with mercury ; but these 
assertions have been refuted by chemists of equal celebrity. In 
our own day, indeed, we find that M. Colson, in a well-written 
memoir, published in the Archives de Medecine, for 1826, assuring 
us that he has detected the presence of mercury in the blood of in- 
dividuals who had taken it, whilst, on the other hand, an equally 
conscientious and skilful observer, M. Devergie, after various 
attempts, could not succeed in detecting it." {Med. leg) 

The question here rested, and chemical analysis had as yet de- 
tected nothing in the milk, when M. Peligot commenced his re- 
searches on the subject. In the Journal des connaissances medico- 
chirurgicales, for November, 1836, he published a memoir on the 
chemical composition of the ass's milk, and in a passage where 
he is treating of the mercurialization of this milk, he remarks: 
"I have made numerous essays for the purpose of detecting the 
presence of mercury at first in the milk of an ass which had taken 
five grains of corrosive sublimate daily, and afterwards in the 
milk of the goat to which twelve grains were given daily, without 
any unpleasant results. Notwithstanding the utmost care, and the 
variety of methods employed, I could not detect the presence of 
the mercury. It cannot, however, be positively affirmed that it 
may not be found in the milk of these animals ; for the best pro- 
ceedings for detecting small quantities leave much to be desired." 

M. Cullerier also made experiments, and took the most favorable 
position for detecting the presence of mercury in the milk of the 
female, and of goats to which he administered this metal. He 
was aided by druggists, and chemists, MM. Lutz, Eeveil, Per- 
sonne. He did not succeed, notwithstanding the utmost persever- 
ance, in discovering but infinitesimal quantities of mercury, after 
analyses made in the best manner possible. 

After these experiments, need we be astonished at the want of 
success, and the fickleness of authors, who, at one time have con- 
demned the direct treatment, preferring that of the nurse, and 
who have subsequently returned to the former method. Thus, 
Faguier and Doublet, who at first greatly lauded the indirect treat- 
ment, afterwards retracted their praises, and without hesitation ad- 
ministered mercury to infants. It should be stated that these 
physicians were at the head of a hospital established for the ex- 
press purpose of carrying out the indirect method of treatment. 
It was the Vaugirard, opened in 1780. At this period, there was 
a diversity of opinion in reference to the best mode of treating 
children at the breast, and no doubt was entertained as to the 
transmissibility of secondary accidents from the nursling to the 
nurse. In this hospital were admitted only nurses who were in- 
fected or pregnant women equally syphilitic who were near their 
accouchement; these women, therefore, could suckle strange chil- 
dren affected with the disease, without risk, and could supply 
them with milk medicated by means of the treatment which they 
themselves were obliged to undergo. 

Bertin, who had charge of the department allotted to nurses in 



484 YIDAL ON VENEREAL DISEASES. 

the Hopital des Cajoucins, was for a long time inclined to the indi- 
rect method of treatment ; but it is evident that his confidence 
sometimes wavered, and he even acknowledges that, under this 
mode, the symptoms were only mitigated or made to disappear, 
with a certainty of reappearing. He goes so far as to express his 
regret that he had not more frequently resorted to the direct 
treatment, for he had had reason to approve it. As if completely 
to contradict theories in favor of the indirect treatment, some 
writers still recommend this method, at the same time that mercury 
is administered to the child, as though such a compromise, says 
M. Cullerier, were not sufficient to settle the value of this indirect 
method. 

As to the treatment with the mercurialized milk of asses or of 
goats, which might be supposed to be more efficacious on account 
of the larger quantity of mercury thus administered at once to 
these animals, the researches of M. Pelligot and of M. Eeveil, by 
which no traces of it could be detected, are certainly well calcu- 
lated to dissipate such a fallacy (Cullerier). 

For my own part, I have never doubted the passage of a small 
quantity of mercury into the milk, both of the goat and of the 
nurse. But my reason for rejecting the indirect treatment is the 
impossibility of regulating the quantity, or of giving sufficient 
doses. Now, in young infants, the progress of syphilis is very 
rapid. We see children born of syphilitic mothers, having the 
appearance of the most perfect health, in the course of four or six 
weeks they are attacked with characteristic symptoms, which, in a 
few days, assume a very serious aspect, and, if the disease be ne- 
glected, soon terminate fatally. "What confidence, in such cases, 
could we repose in the indirect treatment, when the milk of the 
nurse contains so insignificant a proportion of mercury, and even 
that only some days after its administration. I repeat, the pro- 
gress of the disease is very rapid. The treatment, therefore, must be 
energetic. The best method is to give the mercury to the child 
itself, without any apprehension on account of its enfeebled state. 

It may be objected, says M. Cullerier, that the digestive organs 
of these little beings are likely to suffer from the preparations of 
mercury, so that their doses cannot be increased. But then, in- 
stead of giving it internally, it should be administered according 
to the endermic method, by frictions and by baths. Mercury, 
taken internally, has rendered great services ; it has been recom- 
mended by practitioners too reputable, and is still thus adminis- 
tered by those of too high standing, not to inspire confidence in 
the results they profess to have obtained ; but surely this method 
can be indicated only in cases in which the progress of the malady 
is less rapid than usual, and when the constitution is not yet be- 
come too far undermined, or when, indeed, the disease, having 
been arrested by the endermic method, there is some obstacle to 
its continuance, the further administration of mercury being still 
indispensable. Corrosive sublimate is the preparation generally 
employed, and it may be given in milk, syrup, or honey, in the 
dose of a sixteenth, a twentieth, or the twenty -fourth of a grain. 



INFANTILE SYPHILIS. 485 

In the second division of this work, I have already shown how 
feeble is the action of mercury on the mouths of children, either 
when administered internally, or applied to the skin ; but the 
chief risk to be apprehended from its internal use, is its deleterious 
effect upon the stomach and intestinal canal. Children have been 
seen to be attacked with very obstinate vomiting after slight 
doses, and what, according to M. Cullerier, is the predominant 
affection, is enteritis, which destroys most of those thus treated. 

The following is the endermic method of employing mercury : 

The infant should be bathed several times with water, for the 
purpose of allaying any excitement that may exist, and to render 
the skin more favorable to absorption ; fifteen grains of the Nea- 
politain ointment is to be rubbed on the sides of the chest, towards 
the axilla, the application to be made on one side to-day, and on 
the opposite to-morrow. These frictions should be gentle, so as 
not to irritate the skin ; and they should be prolonged for several 
minutes. Twice a week they should be suspended, during which 
the child should take a hot-water bath, to which from half a 
drachm to a drachm of corrosive sublimate has been added. 

In children from two months to one year of age, the above treat- 
ment is generally sufficient, though it may be necessary to in- 
crease the quantity of the mercurial ointment or the corrosive 
sublimate ; but when they have passed this age, the ointment may 
without inconvenience be increased to half a drachm, and that of 
the sublimate in the bath to one and a half drachms. 

M. Cullerier has but one objection to these baths, and this is a 
proof of their efficacy, viz., that when daily employed they cause 
the symptoms to disappear too rapidly, and that, both in hospital 
and in city practice, the parents seeing no longer any evidence of 
disease, are too ready to believe that the cure is perfect, and they 
discontinue all treatment, in spite of the instructions they may re- 
ceive. Well, what then happens ? Why, that in trying to re- 
move the symptoms in too great haste, the specific principle is not 
destroyed, and we have relapses of a malady, of which, as it were, 
we have only skimmed over the surface. 

It is very rare that frictions with the mercurial preparations 
above mentioned, give rise to erythema or a vesicular eruption ; 
besides, it is obvious that in making them on the sides of the 
chest, we act on a broad surface, and thus avoid the irritation 
likely to be produced when made on the legs or thighs, with 
which urine or fecal matters may come in contact. 

When there are mucous tubercles, or ulcerations secretions copi- 
ously on the genital organs, or about the anus, (a circumstance not 
unfrequent,) it is well to touch them occasionally with a solution 
of nitrate of silver, of the strength of one and one-half or two 
drachms to eight ounces of water. If the discharge is moderate, 
or the tubercles are dry, lotions with bran, marsh mallow, or elder 
water, will suffice ; we may sprinkle the surface with starch, farina, 
or lycopodium, (club-moss,) and isolate them as much as possible 
with dry lint, or charpie. 

When the face is attacked, and facial syphilitic impetigo is com- 



486 VIDAL ON VENEREAL DISEASES. 

mon, the same lotions should be employed. The parts being now 
exposed to the air, desiccation is rapid, causing very fine chaps 
and fissures, which are very painful when the child cries or nurses, 
on which account we should cover them as frequently as possible 
with some greasy substance, cucumber ointment, simple cerate, or 
cerate containing opium or calomel. 

M. Cullerier thus concludes : 

" The indirect treatment, or that through the medium of the 
nurse, is insufficient, in consequence of the small portion of mer- 
cury contained in the milk, it is dangerous from the loss of pre- 
cious time in a disease of rapid progress, and which may speedily 
terminate fatally. 

" The direct treatment only is effectual ; it may consist in the 
internal administration of mercury, of frictions, with Neapolitain 
ointment, or corrosive sublimate, baths, means best suited to the 
condition of the digestive organs." 

Since I have described the symptoms of purulent ophthalmia, it 
is proper that I should here allude to its treatment. This does not 
differ from that of the same affection in the adult ; that is, we must 
act directly on the parts, by the most energetic means, such as the 
nitrate of silver in substance. Before resorting to this powerful 
treatment, a great variety of more moderate measures have been 
adopted, many of which have been attended with success, thus 
showing that there are ophthalmic affections which are not of a very 
serious nature. 

As before stated, the nitrate of silver is still the sovereign rem- 
edy, if we really possess a remedy entitled to this name, in the 
treatment of a malady which is occasionally of a very grave char- 
acter, and which terminates in the destruction of the organ. The 
cases reported to the Medical Society of Dublin by Drs. Kennedy 
and Ireland, tend to inspire us with still greater confidence in this 
remedy. These cases are very numerous, and show that this oph- 
thalmia is always cured in two or three days, by the following col- 
lyrium, applied three or four times in the day : 

^ . Nit. Argent. 3 iii. 
Aq. Ros. § viii. 

Antiphlogistics may be employed at the same time : thus there 
are cases where the active nature of the congestion, and the strength 
of the child, require the application of leeches. Sometimes one 
will suffice ; if applied to the upper lid, at a point where the ves- 
sels are much congested, it will discharge blood copiously. 

Hygienic measures should not be neglected, cleanliness being, 
in these cases, absolutely essential. We should frequently inject 
water between the lids, for there is nothing more irritating than 
the matter secreted by an inflamed mucous membrane ; the contact 
of this fluid with the cornea, is one of the most common causes of 
its disorganization. I am convinced, that if we can interpose and 
maintain, without inconvenience, some soft substance between the 
globe and the eyelids, we may prevent, in many cases, the destruc- 



INFANTILE SYPHILIS. 487 

tion of the eye. Thus a child affected with this disease should be 
frequently visited for the purpose of removing this matter which 
tends to adhere to the globe of the eye ; occasionally a hernia forms 
in consequence of the tumefaction of the exuberant mucous mem- 
brane, and the wound is cauterized ; at first it produces severe 
pain, as manifested by the cries of the infant, but it finally subsides, 
and the inflammation disappears soon after the reduction of this 
hernial projection. 



PART FOURTH, 

PROPHYLAXIS OF VENEREAL DISEASES, 



I DO not think that, at the present day, an author is justified, in 
a moral point of view, in teaching the methods of preventing the 
contagion of the venereal disease. On the contrary, he should beg 
the indulgence of the reader for the precepts which, under this 
head, he may inculcate. What, indeed, does he propose? To 
instruct the reader in the means of preventing infection. Now, if 
we sum up the whole of our science, disinterestedly, there is but 
one advice to give, and that is to avoid the source of the poison. 
It is evident that this advice cannot always be followed. We must 
therefore seek other counsel, less certain, but more easy to be ob- 
served, and with this view a private and a public prophylaxis have 
been instituted. 

As to the prophylaxis, in general, it may be said that folly, wis- 
dom benevolence, and charlatanism have vied with each other in 
the effort. Some measures may be found which it would be pru- 
dent to follow ; others, again, are absurd and useless, or even haz- 
ardous. I shall notice only those which possess some utility; 
some there are to which I will merely allude, whilst others will be 
passed in silence, for I am not writing a satire. 



CHAPTER I. 

PRIVATE PROPHYLAXIS. 



Two persons are here concerned ; one fearing to communicate 
the disease, or distrusting himself; the other is exposed to infec- 
tion and would prevent it. 

In the first case, that is, to place such person in circumstances 
least favorable to contagion, he should observe the utmost cleanli- 
ness. All the parts should be most carefully washed. Here, the 
chlorides, soaps, in fine every measure capable of acting chemically 
or physically in altering or removing the morbid secretions, should 
be employed. The parts should be scraped (decajper), to use an 
expression now in vogue in speaking of syphilitic prophylaxis. 



PRIVATE PROPHYLAXIS. 489 

In the second case, that is, when a person is about to expose 
himself to risk, precautions should vary, before and after the con- 
summation of the act. 

Before the act, the parts should be minutely examined to ascer- 
tain whether there is any solution of continuity. The least fissure 
surprisingly promotes contagion. Previous to coition repeated 
lotions with soap are injurious, as they deprive the parts of the 
protection of the smegma and mucosities, and render them com- 
pletely naked, thus placing them in a condition most favorable to 
contagion. Those practitioners who disapprove of these lotions 
before the act, do not regard in the same light those made some 
time previously with solutions of alum, acetate of lead, and parti- 
cularly with aromatic wine alone or combined with tannin. These 
astringents are preferable to fatty substances alone, such as tallow 
and lard, which still enjoy much reputation with those who are 
much exposed to the chancres of infection. An intermediate sub- 
stance, still more efficacious, is the condom already mentioned in 
speaking of blennorrhagia ; it is a small sack made of gold beater's 
skin or the caecum of certain animals, in which the penis is en- 
closed. It should be well washed, new, and perfectly sound. The 
condom, however, leaves the root of the penis, scrotum, genito- 
crural fold, and pubes, exposed, and the pus of a chancre may 
reach, and inoculate these parts ; but it prevents, to a certain ex- 
tent, blennorrhagia, and affections of the glans produced by its 
contact with the neck of the uterus, which, in my opinion, is the 
most frequent point of infection in females. The condom, there- 
fore, is one of the best measures of prevention ; but its cost, and 
the calmness of mind required for its application, are frequent 
causes of its neglect. 

Directions have likewise been given as to the conduct during 
coition. Thus it is recommended that the act be not prolonged, 
that it be hastened, useless advices in many cases, for it is not al- 
ways easy to prolong, and still less, to accelerate the act. Ejacu- 
lation has also been advised, under the idea, that the sudden and 
rapid passage of the semen may carry off the contagious matter. 
Such advice, especially that respecting the rapidity of the act and 
the ejaculation of the semen, has been given by practitioners, and 
this too without the least idea of the difficulty, in the way of com- 
plying with such directions. 

The precautions after coition should be prompt and thorough. 
It has been advised that the person should void his urine. _ True, 
when the bladder contains urine, and it is possible to pass it, it is 
a good practice, for in passing through the canal, it may remove 
the infectious matter from the urethra. Those who have phimosis, 
may close the orifice with two fingers, and fill the preputial cavity 
with urine, which as it leaves the urethra washes the mucous lin- 
ing of the glans and its envelope. But what is of most importance. 
is the application of lotions, to which in the case of a female should 
be added vaginal injections. These lotions should be made to 
reach every part of the mucous membrane ; every fold should bo 
inspected, nothing should be overlooked. Circumstances may 



490 YIDAL ON VENEREAL DISEASES. 

occur in which it is difficult to cany out the measures here recom- 
mended ; thus the necessity of retreating after the act, a false pride, 
the fear of wounding the feelings of the person with whom they 
have had connection, too great confidence, or a state of intoxica- 
tion, may all cause them to be omitted. If one is so fortunate as 
to be able to put the above plan into execution, there is a strong 
jDrobability that contagion will be prevented. The proof of what 
I have here asserted, is the immunity enjoyed by prostitutes, who 
have already paid the penalty of their neglect by syphilitic infec- 
tion. It does not always depend, as M. de Castelneau has always 
supposed, on a kind of syphilitic saturation ; but is most frequently 
the result of the precautions which these women take both before 
and after coition, and the applications of which they make such 
frequent use. This is one of the reasons why we do not find these 
women returning to special hospitals. There is also another, and 
of that I speak in another place ; there are females who though 
registered, find the means of treating themselves, or of being treated 
in houses of prostitution. 

Acids mixed with water were long since recommended as ex- 
cellent lotions. Thus, Lanfranc, in 1290, advised that the penis 
should be washed with vinegar and water. The passage which I 
quote from this author is remarkable not only in a hygienic but in 
an historical point of view, for it has been regarded as a proof of 
the ancient existence of syphilis. It is as follows : "Si quis vult 
memhrum db omni corruptione servare cum recedit a muliere quam 
habet suspectam de immundicitia, lavet illud cum aqua aceto mixtce." 

After Lanfranc, Harrison de Graddesden and Fallopius recom- 
mended the use of urine and of wine, which has lately been highly 
lauded by M. Ricord, especially the aromatic wine. Peyrile 
advises the use of ammoniac, while M. Malapert praises a solution 
of the bi-chloride of mercury. In England it is a common custom 
to wash the parts with water rendered slightly caustic with soap 
and a few grains of fixed alkali, (carbonate of potash.) Males 
inject a little of this solution into the urethra, which I consider a 
bad practice, for the lining membrane of the urethra is easily irri- 
tated, and the injection may produce an urethritis, which, had it 
^een omitted, might not have become developed. 

In Belgium, there is a decree of the burgomaster, requiring a 
flask of oil and a bottle of a solution of the sub-carbonate of potash 
to be placed in each chamber of a house of prostitution. 

M. Eicord has made experiments to ascertain the action of cer- 
tain substances on virulent pus. When he inoculated this pus 
mixed with an alkali or an acid somewhat concentrated, the results 
of the inoculation were negative. These substances decomposed 
the pus, not as some have supposed, in virtue of any specific prop- 
erties, but by their power of destroying matter or organic pro- 
ducts indiscriminately. Sulphuric, nitric, hydro-chloric, and acetic 
acids, and pure chlorides mixed with virulent pus have also pre- 
vented the success of its inoculation; whilst the same subject, on 
whom a pustule was produced by pure pus, that modified by one 
of the substances mentioned produced no effect, even though placed 



PRIVATE PROPHYLAXIS. 491 

side by side with, the first, and under the same conditions for suc- 
cess, with the exception of the neutralizing agent. The same re- 
sults followed the use of the alkaline caustics, such as potash, soda, 
volatile alkali, wine, alcohol, and concentrated decoctions of tannin. 

All are aware of the public experiments made by Luna-Calderon, 
at the venereal hospital in Paris, for the purpose of showing the 
prophylactic power of a substance which he had invented. This 
physician scraped or cut his prepuce, which wound he covered with 
virulent pus. If after this inoculation, his remedy was applied, no 
chancre followed ; if not applied, the inoculation was followed by 
a chancre and sometimes by bubo. Luna-Calderon carried his 
secret with him to his grave.* 

M. Langlebert was more generous. He believed that he had 
invented a prophylactic, and immediately presented it to the public. 
It is composed as follows : 

I£. Alcohol rectified to 40 degrees Cartier, or 95 Gay-Lussac, 3 x. 
Soft soap of potash with excess of base, 3 x. 

Dissolve and filter ; then add : 

Essential oil of rectified citron, 3 v. 

M. Langlebert thus relates his experiments : 

" On Monday last, July 14th, I took pus from the surface of a 
phagedenic chancre, with an indurated base, and immediately in- 
oculated the left thigh of M. E. ; then, steeping my lancet again in 
the same pus, I scraped the right thigh, so as to remove, to a slight 
extent, the epidermis and a part of the surface of the dermis. This 
being done, and wishing to place my proceeding under every pos- 
sible disadvantage, to satisfy myself I repeatedly dipped my lancet 
in the virulent pus, and deposited it all warm and living as it were, 
layer after layer, on the wound which I had made. I then waited 
five or six minutes, when I applied my prophylactic. The next 
day the pus inoculated on the left thigh had produced its customary 
effect : an inflamed pimple, already surmounted by a small vesicle, 
appeared at the punctured point; whilst the right thigh, where 
everything had been done to favor the action of the virus, there was 
nothing but a small scab covering the wound which had been made. 

" This experiment inspired me with so much confidence that I 
did not hesitate to repeat it publicly. On Friday last, July 18th, 
at one of my lectures, I scraped the left arm with a lancet dipped 
in the same pus, and the virulence of which I had proved by inocu- 
lating a monkey, on which a perfect chancre was developed. I 
immediately inoculated two of my students, MM. Albanel and 
Moreau, at their own request. At the expiration of six minutes I 
applied my prophylactic, and at the present time, July 21st, nothing 
has appeared with the exception of a small dry scab over the parts 
scraped."f 

* Vid. Demonstration pratique de la prophylaxic si/philitiqur, authcntiqucnn-nt con- 
stats, by Luna-Calderon. Paris, 1815. 

\ Vid. Lettre adressee le 22 Juillet, 1851, d I'Acadcmie de midccine, par le doctcur 
Langlebert. 



492 VIDAL ON VENEREAL DISEASES. 

To form an estimate of the value of the prophylactic measures 
indicated, two principal circumstances are required : 1st. When the 
pus is deposited only on a sound surface ; 2d. When there is a so- 
lution of continuity or a local manifestation, an effect of the virus. 

It is evident that, in the former case, the mechanical action may 
suffice ; thus lotions with simple water may remove the matter and 
prevent contagion. Everything depends upon the speedy and 
thorough washing of the parts, in fine, on personal cleanliness. 
Alkaline or acid substances may be added to the water, as has been 
already mentioned ; or instead of these we may use aromatic wine ; 
but I doubt their efficacy when used of feeble strength ; they must 
possess great activity to enable them to decompose the pus and 
destroy the virus; they should resemble those which M. Eicord 
mixed with the pus which he was about to inoculate, or their effect 
will be reduced to a simply physical action. Water alone might 
then be equally efficacious. 

In the second case, that is, when there is a solution of continuity, 
and the virus has already produced some effect, simple washing is 
not sufficient. Then, the measures proposed by Luna-Calderon 
and M. Langlebert, offer the greatest pretensions. I doubt their 
being true and certain prophylactics, for even if certain substances 
can destroy the virulence of pus before it has been inoculated, and 
while it remains without the tissues, they may not possess this 
power when it is inserted beneath the skin, and has already en 
tered the system. Having finished his experiments on this sub 
ject, M. Eicord remarks: "But if these substances may be re 
garded as prophylactics by the effects they produce before inocula- 
tion, we should not forget that it was only when the mixture had 
been made at the very moment of inoculation ; for, when pus has 
been, as it were, implanted in our tissues, and the latter have be- 
come infected, unless the parts be destroyed by caustic, to a depth 
exceeding that of the tissues contaminated, a chancre will be de- 
veloped. After the rigorous results of inoculation," adds M. Ei- 
cord, "we cannot depend on the efficacy of the prophylactic meas- 
ures mentioned, except for the purpose of destroying virulent pus 
that has been deposited on a sound surface, or temporarily to 
destroy a virulent secretion in an individual who, without it, might 
have communicated disease. 

As to the means proposed by M. Langlebert, and his experi- 
ments already mentioned, they await the action of a committee 
appointed by the Academy of Medicine ; on which account I for- 
bear to prejudge them. But it will have been remarked that only 
six minutes passed between the inoculation and the application of 
the prophylactic. It is necessary, therefore, that it should be ap- 
plied at once after contagion, which may occur at the commence- 
ment of coition, and the latter be prolonged for more than six 
minutes. If the act is soon accomplished, and the prophylactic 
immediately applied, it may then act only physically, in removing 
the virulent matter. 

I should add, besides, that M. Eicord's cauterization is not cal- 
culated to inspire great confidence. In treating of chancre and its 



GENERAL PROPHYLAXIS.— MEDICAL POLICE. 493 

treatment, in the first division of this work, I have shown how 
rapidly the virus may penetrate the system, and have mentioned 
the remarkable case of Professor Dumeril, who, stung by a viper, 
notwithstanding the immediate suction and cauterization of the 
wound by his son, suffered the general effects of the poison. Now, 
it is well known, that the inoculation of the syphilitic poison has 
always been compared to that of the viper, the justice of which 
comparison has been particularly acknowledged by M. Eicord. I 
believe, therefore, that this physician is not warranted in asserting 
that the cauterization of a wound inoculated with syphilitic pus 
will prevent the formation of a chancre ; and that he is far from 
the truth in stating that this cauterization will prevent constitu- 
tional infection, for he must have forgotten his observations on the 
rapidity of the penetration of the virus into the system, his general- 
izations upon its effects, and especially the advice that he has given, 
to cauterize to a depth exceeding that of the parts contaminated, for in 
a moment the whole system is infected. 

"We see, therefore, to what private prophylaxis is reduced ; it 
amounts, strictly speaking, to nothing more than an observance of 
personal cleanliness. It should, likewise, not be forgotten that 
most of the other measures proposed come under the shield of inoc- 
ulation, which itself is worthy of but little confidence, especially 
since it has been clearly proved that the pus of chancre cannot 
always be inoculated, and that there are individuals who possess 
the power of resisting the action of the most virulent pus. 

I have nothing here to add in reference to the syphilitic vaccina- 
tion with chancrous pus, as proposed by M. Auzias, nor that re- 
commended by M. Diday, with the blood of an individual affected 
with tertiary symptoms, because I have already devoted sufficient 
space to this subject in my Introductory Remarhs, and because I 
have shown, in the second part of this work, that a person may 
have syphilis several times. We may have, then, experimental 
inoculation and physiological inoculation. In speaking of the 
possibility of being infected with syphilis by inoculation, of course 
my remarks are intended to apply only to that proposed by M. 
Auzias, for that of M. Diday has been decided to be quite harm- 
less ; it can do harm only by inspiring the person vaccinated with 
fals£ security. 



CHAPTER II. 

GENERAL PROPHYLAXIS.— MEDICAL POLICE. 

In all ages, the authorities have watched over prostitution ; they 
have even gone so far as to regulate it. We find in ancient 
Greece, that at Athens, inspectors were appointed, to examine into 
the customs and dresses of the females, not, however, in a hygienic 
point of view. Rome, which regulated so categorically houses of 



494 VEDAL OST VENEREAL DISEASES. 

prostitution, and which established a hierarchy among courtezans, 
Eome, which attempted to repress the disorders produced by de- 
bauchery, did nothing in the way of instituting a medical police 
for prostitutes. 

In the middle ages we find new police regulations ; they are 
now more severe, occasionally cruel, and nearly always inefficient ; 
thus, the whip, the confiscation of goods, and even banishment, 
were in turn inflicted by Charlemagne, St. Louis, and the parlia- 
ments, not only on the prostitutes, but on the mistresses of the 
establishments in w hich they were received. It was at this period, 
especially during the reign of St. Louis, that the inutility and 
even dangers of these measures became again manifested. It was, 
therefore, deemed more expedient to regulate prostitution. Un- 
der these regulations we may include those of the London police, 
by which women affected with a scalding were driven from 
houses of prostitution ; regulations followed in Yenice, in 1302. 
At length those famous statutes of Queen Jane were passed at 
Avignon, statutes which have been so often praised, for women 
were no longer driven from their places of abode, but weekly 
visits were ordered, and a true medical police was established. 
Unfortunately these statutes are apocryphal, as shown by the 
researches made at Avignon by Dr. P. Yvaren.* 

In 1449, Parliament began to moderate its severity; it no 
longer banished persons laboring under venereal disease, but made 
an exception in /avor of patients which were poor and had no 
home ; for them it provided an asylum. Finally, in 1536, infected 
persons were no longer looked upon as guilty, but as unfortunate 
sufferers. Parliament still relented even to such an extent as to 
show more humanity than the administrators of hospitals, the nat- 
ural guardians of the sick. Parliaments, indeed, struggled with 
these administrators for twenty-one years, trying to obtain the 
grant of a small hospital connected with the parish of St. Eustache, 
What decrees, what injunctions, what threats were necessary to 
procure shelter for a few suffering mortals ! At that time vene- 
real patients were obliged to obtain fraudulent admission into the 
Hotel Dieu. Again were they banished. At last a special estab- 
lishment was opened for them in the rue de Lourcine, and to the 
magistracy were they indebted for this act. # 

Still it was was not until 1684 that the treatment of these crea- 
tures was ventured upon in a corner of the SaVpetriere, at that 
time a prison for prostitutes guilty of disorderly conduct, Those 
who were sick then received some attention, but what could they 
avail when always preceded by the lash ? And yet we find un- 
fortunate females seeking an arrest with the hope of being sent to 
the Salpetriere, and of there obtaining relief of their sufferings. 
The Salpeiriere having become crowded, the Bicetre was opened to 
venereal patients. This soon became as crowded and unhealthy 
as the jSalpetriere. The history of this period, in reference to 

* Vid. the notes of this physician, appended to his excellent translation into 
French, of the poem of Fracastor. 



GENERAL PROPHYLAXIS.— MEDICAL POLICE. 495 

what was required to obtain admission, the number of patients 
in a ward, the hygiene of this ward, its mortality, is too horri- 
ble for my pen, and I forbear; yet all this happened after 1689, 
an epoch most fertile in philanthropic deeds and in charitable dis- 
courses ! 

Finally, in 1792, the Capucins were opened to the unfortunate 
subjects of syphilis ; this asylum, at present the Hopital du Midi, 
which I have seen in a very bad condition, was regarded as a for- 
tunate abode, though the mortality was one in forty ! True, at the 
Bicetre, it was one in ten ! However, it is from this period that 
the real progress in the treament and hygiene of venereal patients 
begins to date. First of all, they must be sought and isolated, so 
as to withdraw from society these active agents of contagion. 
Hence the idea of subjecting prostitutes to a sanitary inspection. 
The serious application of this idea dates from the ordinance of 
1657; but those women only were examined who, detained at 
the Salpetriere, had suspicious symptoms of the disease. It was 
necessary to extend this ordinance so as to include prostitutes 
at large. This project was formed by several lieutenants of the 
police in the eighteenth century, but they did not dare to put it 
into execution, lest it might compromise their authority in the 
eyes of the public, by appearing indeed to favor the vice, by af- 
fording prostitutes the dangerous privilege of a certain security. 
Finally, under the prefecture of Dubois, in 1800, this project as 
well as certain others temporarily required by the economists, and 
always regarded as chimerical, were actually carried into execu- 
tion. From this time, we have a true medical police, since their 
authority was not limited to the suppression of the vice, but in- 
cluded likewise sanitary considerations. Two practitioners, Cou- 
lon and Teytaut, were charged to visit periodically houses of pros- 
titution, the expense being borne, by the prostitutes themselves, 
who paid a monthly tax of three francs. Even a consulting hall 
was established, where females unable to obtain admission to the 
hospital, received advice and medicine gratuitously, thus permit- 
ting them to be treated among themselves. This establishment 
received the name of Dispensaire de Salubrite. 

There is at present, in every town in France, a dispensary, but 
the ancient tax imposed on the prostitutes having been abolished 
in 1818, the expense is borne by the municipality. Were I to 
assert that these dispensaries are perfect, I should state that which 
is absurd. At these institutions the visits are generally made. In 
Paris the prostitutes, living by themselves, are examined twice a 
month. In many of the towns they are visited weekly. It is 
necessary that this rule should never be violated, and that tliey should 
never be treated by themselves. When once it is known that a female is 
diseased she should be removed at once to a special hospital, and there re- 
main until entirely cured. I purposely underline these remarks 
A number of females, of every occupation, whom poverty or de 
bauchery induce to lead a life of prostitution, escape the police 
Here is one of the dangers of a medical police, and yet these are 
the women who infect the greatest numer of young men ! 



496 VIDAL ON VENEREAL DISEASES. 

Girls in houses of prostitution are visited weekly, and whenever 
thej change their residence. When one is found diseased she 
should be actually and immediately conducted to a special hospital, 
and not fraudulently to another hospital. They should never be 
treated in these houses under the promise that they will not have 
connection during their treatment. Experience has taught us 
what value to place on the promises of the mistresses of these es- 
tablishments. Every girl whose health there is reason to suspect 
during the interval between the visits, should at once be taken to 
a hospital and examined. 

The inefficacy of the medical police arises, I repeat, from the 
fact that certain girls are treated by themselves and in the houses 
of prostitution, where they still scatter the disease ; another reason 
is that the visits are not sufficiently frequent, for the mean period 
of incubation is four days ; consequently, a woman who shall have 
received the germ of the disease on the evening or day before the 
visit, will appear to be sound and receive a certificate to that effect, 
and yet she will for seven entire days be capable of communicating 
the disease to those who have connection with her. 

At these visits the girls should be examined with the greatest 
care. We should not be satisfied with that of the external organs 
alone, but with that of the speculum we should explore the vagina 
and the neck of the uterus. The most convenient speculum for 
this purpose is the bi- valvular instrument. In some cases, it may 
permit a portion of the mucous membrane to portrude between 
the branches, at the time of their separation, and may sometimes 
pinch this membrane when it is withdrawn. To obviate this in- 
convenience, it has been proposed to add two other valves,' which 
are easily united and separated from it, thus facilitating its intro- 
duction. But a little precaution and tact will render such addition 
unnecessary. 

The female should be placed upon a table in the same position 
as if to undergo lithotomy, or she may sit on an arm-chair, or lie 
on a bed ; the legs should be flexed upon the thighs, and the latter 
upon, the pelvis. The speculum, well oiled, is held in the right 
hand ; with the left the operator separates the labia majora and 
the right labia minora, an assistant separates at the same time those 
on the left side. If no assistant be at hand, the left middle finger 
should be applied over the fourchette, whilst with the other fingers 
the labia are separated; the extremity of the closed instrument is 
made to rest upon the middle finger in such a manner as not to 
press against the urethra and superior orifice of the vagina. Dur- 
ing the introduction of the instrument we should be careful to 
press upon the fourchette so as to efface a small cul-de-sac which 
exists behind it, for it may obstruct the operation, or give rise to 
pain if an attempt be made to force the passage of the instrument. 
The vulvar ring having been passed, the instrument is glided on 
from below upwards and from before backwards, and as it passes 
on towards the uterus, we examine the parts exposed. 

The vaginal walls applied against the instrument form a kind 
of rose with an opening at its centre, and at its circumferance the 



GENERAL PROPHYLAXIS.— MEDICAL POLICE. 497 

natural folds of the canal. "We know that we have reached the 
neck of the uterus by the absence of the folds and a change of 
color in the lining membrane, but more particularly by the ap- 
pearance of the os tinea?. It is sometimes difficult to isolate it with 
the valves of the instrument, either on account of its deviation, or 
the particular position in which the female has been placed. The 
examination is concluded by slowly withdrawing the speculum, 
by which proceeding the whole extent of the vagina is again 
brought into view. This second inspection may sometimes expose 
lesions which escaped notice at the first examination. 

The subject of general prophylaxis cannot be completed with- 
out referring to the means of preventing the spread of contagion 
by the male. But if we have already discovered the difficulties 
attending the visits of inspection of the female, whom the laws, as 
it were, have placed at our disposal, what can we expect when we 
come to the male, to whom the right of visit does not extend. In 
the army the case is different ; there, discipline and subordination, 
and interests easy to be appreciated, have ^rendered possible the 
detection of the malady, and the immediate application of the 
remedy. In the first place, the punishment indiscriminately in- 
flicted on soldiers with the venereal disease, on their discharge 
from a hospital or infirmary, has been abolished, and thus soldiers 
no longer conceal the existence of affections, which they suppose 
to be venereal ; they can now seek assistance from the surgeon 
without apprehension ; their cure is therefore more speedy, an ad- 
vantage both as regards their own health, and the propagation of 
the malady. 

The minister of war has recommended to the commanders jn the 
army, and to the heads of the administration, to unite with the 
civil authorities in opposing, to every possible extent, the spread 
of a scourge so disastrous in its effects to the public as well as to 
the army. These recommendations have produced beneficial re- 
sults, but we could hope for still better, if the instructions were de- 
cided, simple and precise, so as to insure their execution. 

In Belgium, the medical inspector-general of prostitutes is di- 
rectly associated with the heads of the venereal hospitals, and after 
each admission the name and residence of the person who has com- 
municated the disease are taken. In a circular from the inspector- 
general of the army, bearing date of December 21, 1842, M. Ylem- 
inckz issued to all the heads of the military hospitals, the following 
regulation adopted in the garrison at Liege : 

"Every person found diseased, is immediately interrogated by 
the officers and sub-officers of his company who have received an 
order from their chief; a corporal accompanies the patient with 
the commissary of police to the residence of the woman infected. 
This agent takes their depositions, arrests her, causes her to be 
examined, and sent to a dispensary ; he furnishes the corporal with 
a duplicate of the soldier's testimony, the corporal takes him to the 
hospital, and the document is delivered in custody to the surgeon. 
In the absence of this individual, the health officer of the establish- 
ment surrenders him at once to the person in command. No ye- 

32 



498 VIDAL ON YENEKEAL DISEASES. 

nereal patient can be treated in the barracks. Soldiers are severely 
punished if they fail to make known their attacks, as are those 
who, by false statements, prevent the search for an infected prosti- 
tute, but for those only. The inspector-generals maintain frequent 
communication with the physician in charge of the syphilitid wards 
for soldiers. 

"Such," says M. Yleminckz, "are the advantages of these regu- 
lations, that in 1845, out of a force of from twenty-five to thirty 
thousand men, in the Belgian army, there were but one 'hundred 
and fifty affected with venereal disease, (one patient out of one 
hundred and ninety soldiers.) There would not," he observes, 
"have been one hundred, if the sanitory police at Gand and at 
Kamur had acted efficiently."- M. Bertherand, who mentions with 
approbation these regulations, adds : " Now contrast this with what 
occurs in France ! At the venereal hospital in Strasbourgh there 
are daily from one hundred to one hundred and fifty patients ; ii 
we add to this an equal number of cases of urethritis, and the 
milder forms of chancre, treated in the regimental infirmaries, we 
find that eight thousand men in garrison furnish, first, as many 
venereal patients as are found in the whole Belgian force ; second, 
the sextuple proportion of one syphilitic patient to thirty-three 
men. If we consult the table, at the commencement of this work, 
of cases treated in our hospital from 1836 to 1846, calling the price 
of one day one franc, we shall find that the mean cost, on the budget 
of war, of syphilis, at Strasbourg, is nearly forty thousand francs 
per annum. 

" Why, in our barracks, is not the head of department conjointly 
responsible, to a certain extent, for the prevention of disease ? The 
severe punishment of the venereal soldier having been abolished, 
the deposition of the brigadier or corporal has lost all its odious 
character. Their repugnances once overcome, it well be easy. to 
make men of standing, like the heads of department, understand 
that it is as much for the morality and dignity of the corps to de- 
tect a soldier that would conceal the venereal disease, as one affect- 
ed with the itch, or any other contagious malady. 

" With false notions of hygiene, the soldier should no longer be 
shut out of public houses, known and examined, and be reduced 
to the resources of clandestine prostitution. Surely it is better to 
overlook visits to the former, and redouble our vigilance as regards 
these private women, in which all large towns abound. Females 
who are not subjected to examination, who have a thousand plans 
for escaping sanitary visits, are the most dangerous of all pros- 
titutes. 

" The measures proposed by the inspector-in-chief of the health 
of the army in Belgium, supposes perfect harmony and constant 
intercourse between the local authorities and the officers in com- 
mand, aided by the army surgeons. With us, the number of in- 
termediate agents impede the progress of matters, if they do not 
render it impossible by the obstacles they present, and the disgust 
which they inspire. The distribution of the corps, the frequent 
changes of the health officers, do not allow them to establish with 



GENERAL PROPHYLAXIS.— MEDICAL POLICE. 499 

special physicians, the intercourse indispensable to success in pre- 
venting the spread of the venereal disease."* 

I here terminate my remarks on prophylaxis, stating that the 
idea of obtaining from each patient admitted into a hospital, and 
every practitioner consulted, the name and residence of the parties 
who communicated the disease, and that of granting to every phy- 
sician authority immediately to arrest such person — ideas partly 
carried into execution in the Belgian army, would, if adopted in 
civil life, produce the most happy results. But I touch here upon 
a delicate question, which I propose hereafter to discuss in a man- 
ner commensurate with its importance. 

* Bertherand, Precis des maladies veneriennes. Strasbourg!!, 1852. 



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